Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lumbar intravertebral disc injection 
procedure (code 0627T). 
 
You asked the Plan to pre-approve percutaneous lumbar intravertebral disc injection procedure. You say that 
the percutaneous lumbar intravertebral disc injection procedure is medically necessary. The Plan denied your 
request. The Plan says the requested percutaneous lumbar intravertebral disc injection procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous lumbar intravertebral disc 
injection procedure. Our reviewer says that the requested percutaneous lumbar intravertebral disc injection 
procedure is not considered medically reasonable and necessary. Our physician reviewer found that the provider is requesting the injection of VIA Disc into the spinal disc for advanced degenerative disc disease 
against Food and Drug Administration (FDA) approval guidelines. Large well-designed studies in the peer 
review scientific literature comparing stand-alone use of VIA Disc to established treatments are 
needed. Published studies do not demonstrate any long-term health outcome advantage with the use of VIA 
Disc NP as an alternative to standard treatments. The review has determined that the requested percutaneous 
lumbar intravertebral disc injection procedure at issue in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous lumbar intravertebral disc injection procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous lumbar intravertebral disc 
injection procedure (code 0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has severe COPD and HFrEF.  The enrollee has had two recent hospitalizations 
with arterial blood gas (ABG) tests showing acute on chronic hypercarbic respiratory failure. Although there is 
no ABG done while stable, this enrollee may well have chronic CO2 retention. The enrollee may benefit from 
bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep 
as an outpatient. This has not been tried and shown to fail as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. Therefore, the enrollee does not meet criteria 
for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 16, 
2022. 
 You asked the Plan to pay for procedure code 99214. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code 20552. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 
is a column II code to column I code 20552. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary. The Plan denied 
your request. The Plan says out-of-network services are covered only in certain limited circumstances which 
have not been met in this case. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue, and these services were not referred by a contracted provider. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided on November 11, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Abatacept (Orencia). 
 
You asked the Plan to pre-approve Abatacept. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Abatacept. Our reviewer says that the 
documentation does support that the requested drug meets step therapy criteria. Our physician reviewer found 
the enrollee has a diagnosis of Arthropathic psoriasis, unspecified. While the enrollee has not tried and failed 
Remicade or Simponi Aria, the documentation shows that Remicade or Simponi Aria would be more likely to 
have adverse effects than Abatacept (Orencia) for the enrollee in this case. Therefore, the enrollee meets 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abatacept have been met. Therefore, we decided that the Plan has to pre-
approve Abatacept (Orencia).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Northera. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Northera.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99221-25) provided on June 20, 2022. 
 
You asked the Plan to pay for hospital care. You say that this should be covered. The Plan denied your request. 
The Plan says the records do not support this was a separate service. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -25 is used to report a significant, 
separately identifiable evaluation and management service by same physician on the day of a procedure. The 
physician may need to indicate that on the day a procedure or service that is identified with a code was 
performed, the patients condition required a significant, separately identifiable evaluation and management 
service above and beyond the usual preoperative and postoperative care associated with the procedure or 
service that was performed. 
 We looked at the file and Medicare rules. The submitted records do not support that the billed hospital care was 
a significant, separately identifiable evaluation and management service above and beyond the usual 
preoperative and postoperative care associated with the catheter insertion (36558) performed and billed on the 
same day. Based on this information, we decided that Medicare rules for coverage of hospital care have not 
been met. Therefore, we decided that the Plan does not have to pay for hospital care (99221-25) provided on 
June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee's care can be provided in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
(3) visits weekly to regain or maintain their functional status. The enrollee can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
(3) visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services 
at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64461 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 64461. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 64461 is bundled into payment for code 36625. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64461 
is a column II code to column I code 36625. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 64461 billed for date of service November 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The member continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that the 
enrollee would meet criteria for admission to an acute inpatient rehabilitation facility.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services billed with code 99397 for date of service 
November 11, 2022. 
 
You asked the Plan to pay for code 99397. You say that this claim was coded correctly. The Plan denied your 
request. The Plan says this claim is not payable. The Plan must follow Medicare rules. Medicare rules say that 
code 99397 is noncovered. Therefore, we decided that the Plan does not have to pay for outpatient services 
billed with code 99397 for date of service November 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on November 22, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and is supported 
as billed. The Plan denied your request. The Plan says that the code used to report the services provided is not 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records provided support 
that drugs from 19 drug classes were tested in this case. Based on this information, we decided that Medicare 
rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive 
drug testing (G0482) provided on November 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 3, 2022, to 
February 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 3, 2022, to 
February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided March 8, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you believe that the device was 
medically necessary after knee surgery to prevent clots. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided March 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medical services from an out-of-network (OON) nurse practitioner 
provided on March 27, 2022. 
 
You asked the Plan to pay for the medical services provided by an OON nurse practitioner. You say that the 
services were urgently needed due to your medical condition. The Plan denied your request. The Plan says that 
they contacted the facility to request a valid Provider Transaction Access Number (PTAN) letter for the date of 
service March 27, 2022, which they did not have. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any medical records, evidence of call logs 
to the provider, or claim submission documentation. The case file shows that the Plan deemed this hospital stay 
emergent and paid other portions of the claim a the in-network rate. The Plan has not substantiated their denial 
reason or supported that the enrollee should be held liable for the services in dispute. Therefore, we decided 
that the Plan has to pay for medical services from an out-of-network (OON) nurse practitioner provided on 
March 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.