Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram and the echocardiogram provided on 
October 16, 2023. 
 
You asked the Plan to pay for the electrocardiogram and the echocardiogram. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the electrocardiogram and the echocardiogram provided on October 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF care provided from June 1, 2023, 
to June 26, 2023. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were not informed that you 
would be billed. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment per day, for days 1 to 20, and a $196 copayment per day, for days 21 to 61, for in-network skilled 
nursing facility care.  
 
The record shows you received SNF care from May 26, 2023, to June 26, 2023. You have been asked to pay 
$140, which is a $10 copayment per day, for days 7-20, for the SNF care provided June 1, 2023, to June 14, 
2023 ($10 copayment x 14 days = $140). You have also been asked to pay $2,156, which is a $196 copayment 
per day, for days 21-31, for the SNF care provided from June 15, 2023, to June 25, 2023 ($196 copayment x 11 
days = $2,156). You have been asked to pay a total of $2,296 ($140 copayment + $2,156 copayment = $2,296). 
You have not been charged for the day of discharge. This item/service falls within the skilled nursing facility 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided from June 
1, 2023, to June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of an implantable loop recorder system 
provided on August 13, 2023. 
 
You asked the Plan to pay for remote monitoring of an implantable loop recorder system. You say that you are 
appealing the denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for remote monitoring of an implantable loop recorder system provided on August 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. You say that this is medically necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Byooviz. 
 
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 
step therapy criteria for Vabysmo have not been met. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the preferred drug, Byooviz. The reviewer found that there is no 
documentation provided indicating that the Plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
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 (J2777).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Mycophenolate Mofetil Tablet 500mg. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the requirement for the 
requested drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the medication. Our reviewer says that 
the enrollee does not meet the criteria for the requested drug. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of seropositive myasthenia gravis. The Food and Drug Administration (FDA) 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia do contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
The local coverage rule excludes coverage of immunosuppressive drugs not prescribed for the specific labeled 
indications and approval for marketing by the FDA. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Mycophenolate Mofetil Tablet 500mg.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says admission to the IRF is not medically necessary.  
 
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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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 IRF. Medically necessary care can be provided in a different 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1843 and L2397) provided on February 10, 
2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show documented knee instability, recent knee injury, or a recent 
surgical procedure to the knee. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee has not had recent surgery or a recent injury. The documentation doesnt 
support that the joint is unstable or that there is joint laxity. The requested knee orthosis is not medically 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1843 and L2397) provided on February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1843 and L2397) provided on November 2, 
2022. 
 
You asked the Plan to pay for the services. You say that the medical records indicate the need for this brace. 
The Plan denied your request. The Plan says the records do not show any documentation of knee instability, or 
any recent injury or surgery to the knee. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee has not had recent surgery or a recent injury. The documentation doesnt 
support that the joint is unstable or that there is joint laxity. The requested knee orthosis is not medically 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1843 and L2397) provided on November 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve prostate artery embolization (PAE). You say that you are requesting a 
reconsideration stating that the medical records support this service. The Plan denied your request. The Plan 
says prostate artery embolization (PAE) is not supported by current data, and benefit over risk remains unclear; 
therefore, PAE 
is not recommended outside the context of clinical trials. 
 
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 prostate artery embolization (PAE). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is a preservice request for prostate artery embolization. In the absence of more compelling data, embolization appears to be experimental, especially in the absence of trialing 
medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization (PAE) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve prostate artery embolization (PAE).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the peripheral nerve block injection described by code 64447 
performed on date of service December 12, 2022. 
 
You asked the Plan to pay for 64447. You say that 64447 should be paid as billed because it is supported in the 
medical record. The Plan denied your request. The Plan says that 64447 is denied because payment for this 
service is bundled into payment for code 01402. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block may be separately 
reported on the same day as an anesthesia code 0XXXX if the mode of intraoperative anesthesia is 
subarachnoid injection, the adequacy of the intraoperative anesthesia is not dependent on the nerve block, it is 
administered for postoperative pain management at the request of the surgeon, and modifier -59 is appended. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the peripheral nerve block injection 
described by procedure code 64447 was performed on the same date as anesthesia code 01402. Records 
indicate the enrollee had a right total knee arthroplasty for which the primary mode of anesthesia was spinal 
(subarachnoid injection). Records clearly indicate that 64447 was intended for and administered for 
postoperative pain management at the surgeon's request. Per Medicare rules, if the mode of intraoperative 
anesthesia is subarachnoid injection, as it is in this case, a peripheral nerve block for postoperative pain 
management performed at the request of the surgeon may be reported separately with modifier -59 appended. 
We have confirmed that 64447 was billed with modifier -59. Separate reporting of a nerve block injection for 
postoperative pain management does not necessarily require that the nerve block must be administered 
postoperatively. Per Medicare rules, it may be administered preoperatively, intraoperatively, or postoperatively. 
Based on this information, we decided that Medicare rules for coverage of 64447 have been met. Therefore, we decided that the Plan has to pay for the peripheral nerve block injection described by code 64447 performed on 
date of service December 12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on May 27, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided 
on May 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service September 
28, 2023.   
You asked the Plan to pay for procedure code 88341. 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 88341 is 13. The MAI value for this code is 3. You billed 14 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service September 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided on August 25, 
2023, to August 29, 2023. 
 
You have asked the Plan to waive the copayment for the hospital stay. You say that you were not made aware 
of being charged for the additional days spent in the hospital. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment for days 1 through 5 for Medicare-covered in-network inpatient hospital care each time you are 
admitted. There is a $0 copayment for additional Medicare-covered days. 
 
You have been asked to pay $1,950, which is a $390 copayment for days 1 through 5 of the inpatient stay from 
August 25, 2023, to August 29, 2023 ($390 copayment x 5 days = $1,950). These services fall within the 
inpatient hospital care services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient stay provided from August 25, 2023, to August 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says this 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 the provided records do not show magnetic resonance imaging (MRI) showing 
only Modic changes without facet degenerative joint disease or stenosis. The reviewer found that the records indicate multiple potential sources of pain. Therefore, the reviewer found that the requested Intracept procedure 
is not medically reaosnable 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 7, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 9, 2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the outpatient services are included in the inpatient 
stay. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, there are no medical records for the inpatient hospital stay to verify if the outpatient 
services were related to the stay. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on August 9, 2023.