Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator and a high frequency chest wall oscillation 
device. 
 
You asked the Plan to pre-approve a ventilator and a high frequency chest wall oscillation device. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
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 and a high frequency chest 
wall oscillation device. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to 
confirm chronic carbon dioxide (CO2) retention. If that is present, the enrollee may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. A high-frequency chest wall oscillation device for airway clearance is not medically necessary. There is 
inadequate evidence supporting the safety and efficacy of this device in the treatment of chronic obstructive 
pulmonary disease (COPD). 
 
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 and a high frequency chest wall oscillation device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a ventilator and a high frequency chest 
wall oscillation device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service December 9, 
2022. You asked the Plan to pay for procedure code 88291. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88291 is 1. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service December 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) quantitative calcium 
scoring. 
 
You asked the Plan to pre-approve CT calcium scoring. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this screening test is not covered by Medicare. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, CT calcium scoring, is being requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve computed tomography (CT) quantitative calcium scoring.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you need to attend dialysis. The Plan denied 
your request. The Plan says your benefit only allows 48 trips for this service. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. We find that once you have used 48 one-
way trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says you do not meet Medicare guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that you are improving but still require acute care services 
before transitioning to a lower level of care. You continue to receive acute care services, and these have not 
been denied. Our reviewer found that the medical record does not indicate you require services that you are not 
currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
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. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve routine transportation. You say that you need this transportation for an 
office consultation with your doctor. The Plan denied your request. The Plan says the requested destination is 
beyond 75 miles per one-way trip. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 75 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast reduction and associated procedures to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve breast reduction and associated procedures to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
breast reduction and associated procedures to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documentation of an inability to tolerate non-invasive conservative care or medical documentation of failure to 
respond to four (4) weeks of noninvasive conservative care such as physical therapy. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97535 billed for date of service December 
16, 2021. 
 You asked the Plan to pay for procedure code 97535. You say that this is a covered service. The Plan denied 
your request. The Plan says payment for code 97535 is bundled into payment for code 97530. 
 
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 97535 
is a column II code to column I code 97530. 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 97535 billed for date of service December 16, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Ruxience. 
 
You asked the Plan to pre-approve Ruxience. You say that there aren't many other options left for the enrollee. 
The Plan denied your request. The Plan says the clinical value and effectiveness of Ruxience in the setting of 
hypersensitivity pneumonitis have not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ruxience. Our reviewer says that the 
enrollee does not meet criteria for use of Ruxience. Our physician reviewer found Ruxience is not Food & 
Drug Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Ruxience.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the requested Intracept 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the literature indicates that the Intracept procedure targets the basivertebral 
nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system 
unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Intracept device to established surgical decompression are needed. Published 
studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative 
to standard surgical treatment. In this case, the review has determined that the requested Intracept procedure is 
not medically reasonable or necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix (J1447). 
 
You asked the Plan to pre-approve Granix. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested use of Granix is not approved by the FDA 
for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Granix. Our reviewer says that the 
requested drug, Granix, is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of drug induced agranulocytosis in the setting of immunosuppressive treatment for a 
kidney transplant. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested use of 
Granix 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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix (J1447).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the treatment is recommended to reduce 
the risk of complications. The Plan denied your request. The Plan says that the service is unproven for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the requested services. Our physician 
reviewer found that for this enrollee, reirradiation complicates the treatment plan and the letter of appeal 
describes the need for proton therapy using composite dose measures. Based on the submitted plan comparison, 
it is plausible that proton therapy would offer a reasonable, clinically meaningful benefit with respect to sparing 
the lungs and heart, and also would allow optimal target coverage while adhering to accepted normal tissue 
constraints. Thus, for this enrollee, proton therapy can be considered medically necessary and would be within 
the accepted standards 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam radiation therapy.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from March 22, 2021, to 
April 27, 2021. 
 
You asked the Plan to pay for infrared therapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says infrared therapy is considered not reasonable and necessary by Medicare 
and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Based on this 
information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided from March 22, 2021, to  
April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 13, 2022, billed 
with codes 81227, 81231, 81232, 81238, 81291, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 13, 2022, billed with codes 81227, 81231, 81232, 81238, 81291, 81306 and 81335.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic colonoscopy (45378) billed for date of service 
November 14, 2022. 
 
You asked the Plan to pay for a diagnostic colonoscopy. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 45378 is: Colonoscopy, flexible; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for a diagnostic colonoscopy. Our reviewer says that CPT code 45378 does not meet criteria for payment. Our reviewer found that CPT code 45378 denotes a diagnostic 
colonoscopy. However, the indication offered for the enrollee's study was 'screening.' Risk assessment was not 
provided, nor was a history and physical supplied to determine risk. The enrollee met criteria for screening 
colonoscopy codes G0121 or G0105. However, the reported CPT code for a diagnostic colonoscopy was 
incorrect. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a diagnostic colonoscopy have not been met. Therefore, we decided that the 
Plan does not have to pay for a diagnostic colonoscopy (45378) billed for date of service November 14, 2022.