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

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (64555). 
 
You asked the Plan to pre-approve a Sprint peripheral nerve stimulation (PNS) system. You say that the 
requested PNS system is medically necessary. The Plan denied your request. The Plan says PNS is unproven 
and not medically necessary due to insufficient evidence of efficacy. 
 
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 a Sprint PNS system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Sprint PNS device is experimental and investigational for chronic pain treatment. 
There is more research needed due to efficacy. 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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(64555).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on March 22, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this panel of tests should be billed with a single procedure code. 
 
The Plan follows Medicare rules. Medicare rules state that tests performed in parallel are considered part of the 
same panel  
 
We asked our coding 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 pay for lab tests. Our reviewer says that these codes 
do not meet criteria for payment. Our physician reviewer found support was not found in the records for the 
multiple genes reported. One procedure code should be reported. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service May 30, 
2023.  
 
You asked the Plan to pay for procedure code 77002. You say that you disagree with the denial. 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 77002 is 1. The MAI value for this code is 3. You billed 2 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 77002 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 77002 billed for date of service May 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Dexamethasone sodium phosphate, 
Magnesium sulfate, Famotidine, Cathflo, Diphenhydramine Hcl, Pemetrexed, and Carboplatin. 
 
You asked the Plan to pre-approve Keytruda, Dexamethasone sodium phosphate, Magnesium sulfate, 
Famotidine, Cathflo, Diphenhydramine Hcl, Pemetrexed, and Carboplatin. 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 Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda, Dexamethasone sodium phosphate, Magnesium sulfate, Famotidine, Cathflo, Diphenhydramine Hcl, Pemetrexed, and Carboplatin. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested drugs 
are not FDA-approved for the enrollees diagnosis without estimated glomerular filtration rate (EGFR) 
resulted. The use are supported by one of the major drug compendia or by clinical research that appears in a 
CMS-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 Keytruda, Dexamethasone sodium phosphate, Magnesium sulfate, Famotidine, 
Cathflo, Diphenhydramine Hcl, Pemetrexed, and Carboplatin have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Keytruda, Dexamethasone sodium phosphate, Magnesium sulfate, 
Famotidine, Cathflo, Diphenhydramine Hcl, Pemetrexed, and Carboplatin.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74174 billed for date of service June 20, 
2023.   
You asked the Plan to pay for procedure code 74174. You say that the claim is billed correctly and should be 
paid. 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 74174 is 1. The MAI value for this code is 3. You billed 2 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 74174 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 74174 billed for date of service June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device/appliance billed with code E0486 for date of 
service March 29, 2023. 
 
You asked the Plan to pay for the oral device/appliance. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee did not meet criteria for the item rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances are only covered when the 
enrollee has had an in-person clinical evaluation by the treating practitioner prior to the sleep test. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee had an in-person 
clinical evaluation by the prescribing provider. Based on this information, we decided that Medicare rules for 
coverage of the oral device/appliance have not been met. Therefore, we decided that the Plan does not have to 
pay for the oral device/appliance billed with code E0486 for date of service March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 26, 2023, to 
January 29, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that sepsis, 
unspecified organism is the correct principal diagnosis. The Plan denied your request. The Plan says the 
Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient 
hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism. 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 pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found the enrollee was treated in the hospital with 
uncomplicated diverticulitis. Workup and evaluation revealed a normal platelet count, normal bilirubin, and 
creatinine 1.80 mg/dL. The enrollee was alert and oriented, without oliguria, hypoxia, or hypotension. Blood 
culture was without growth. Sepsis-3 criteria was not met as there was insufficient support found in the 
documentation that the enrollee had organ failure directly related to a dysregulated response to systemic 
infection. Therefore, the code, A41.9 (sepsis) is not supported and DRG 391 appears to be most appropriate for 
this admission based on the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 26, 2023, to January 29, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service July 29, 
2023.  
 
You asked the Plan to pay for procedure code A0425. You say that the patient had to be transported to a more 
distant facility. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.   
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 279 units of 
this code on a single claim line, exceeding the MUE. The units in excess of the MUE were not reported on a 
separate claim line with an appropriate modifier as required. Based on this information, we decided that 
Medicare rules for coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A0425 billed for date of service July 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Registered Nurse 
First Assistant (RNFA) on June 15, 2023. 
 
You asked the Plan to pay for the RNFA services. You say that the services of the surgical assistant were 
requested by an in-network surgeon. The Plan denied your request. The Plan says RNFAs are not payable 
providers for Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Registered Nurse First Assistant (RNFA) on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for March 23, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99306 is not supported. 
 
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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99306 is not supported. Our reviewer found the enrollee presented with fatigue and dehydration. The records support 
that an appropriate examination was performed, but not an appropriate history or medical decision making of 
high complexity. Code 99306 is therefore not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99306 billed for March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the periodic oral 
evaluation (D0120), and the topical application of fluoride varnish (D1206) provided on August 16, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the periodontal maintenance (D4910), the periodic oral evaluation (D0120), and 
the topical application of fluoride varnish (D1206). You say that you were told that these services would be 
covered. You say you called the provider twice to verify coverage of your dental services. The Plan denied 
your request. The Plan says the services were provided by an out-of-network provider. 
 
 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 did not pre-approve the 
dental services. We found no exception that would require the Plan to pay for the dental services. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910), the periodic oral 
evaluation (D0120), and the topical application of fluoride varnish (D1206) provided on August 16, 2023, by 
an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (faricimab-svoa) (J2777). 
 You asked the Plan to pre-approve Vabysmo. You say that this is a medically necessity for the enrollee's 
treatment for moderate non-proliferative diabetic retinopathy with macular edema.  The Plan denied your 
request. The Plan says this request does not meet the Plan's step therapy criteria for the requested drug.  
 
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 Vabysmo. Our reviewer says that the 
Plan's criteria for coverage has not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug (Avastin/bevacizumab). 
Based on the medical records provided and the Medicare-approved major drug compendia there is no 
indication that the Plan's required drug (Avastin/bevacizumab) would likely be less effective and/or likely have 
adverse effects 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (faricimab-svoa) (J2777).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without this device, the enrollee will have a 
high risk of recurring hospitalizations and continued decline in her health. The Plan denied your request. The 
Plan says the request is not medically necessary because the records show that the ordered settings for the 
ventilator show it is going to be used only in a bi-level pressure mode. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and obesity 
hypoventilation syndrome (OHS) with chronic respiratory failure. Although there is mention of failed BIPAP, 
there is no supporting documentation showing failure. A reasonable approach would be to attempt BIPAP with 
average volume-assured pressure support (AVAPS) and if that fails then consider escalation. At this time, there 
is not adequate documentation to support a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87633, 87798, 
87641, and 87500 for date of service July 25, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87491, 87563, 87640, 87633, 87798, 87641, and 87500. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are 
not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87633, 87798, 87641, and 87500 are not payable as 
billed. Specifically, procedure codes 87481, 87563, 87798, 87641, 87633, and 87500 are not supported as 
billed as they are for a panel that was billed unbundled. There is a more appropriate lab panel code that should 
be billed when one or more codes are included in the same panel. Code 87491 was not supported as the 
documentation submitted did not include documentation of a physician order or laboratory requisition for the 
billed test. We have confirmed that code 87640 is a column II code to column I code 87641. Although code 
87640 was billed with modifier -59, the medical records provided do not show that the service billed with the -
59 modifier is a distinct procedural service. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87481, 87491, 
87563, 87640, 87633, 87798, 87641, and 87500 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 87481, 87491, 87563, 87640, 87633, 87798, 87641, and 87500 for date of 
service July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service July 14, 
2023. 
 You asked the Plan to pay for procedure code 11720. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 11720 is bundled into payment 
for code 11719. 
 
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 11720 
is a column II code to column I code 11719. 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 11720 billed for date of service July 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Keytruda is not FDA-
approved for the enrollees diagnosis with progression on prior immunotherapy. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.