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

 
We decided that the Plan does not have to pre-approve anticancer treatment with Abraxane (J9264) and 
Keytruda (J9271). 
 
You asked the Plan to pre-approve Abraxane and Keytruda. You say that the requested regimen is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested regimen has been 
prescribed for an off-label, not medically accepted use. 
 
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 Abraxane and Keytruda. Our reviewer 
says that treatment with Abraxane and Keytruda is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Abraxane and Keytruda is not FDA-approved for the 
enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that 
appears 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 Abraxane and Keytruda have not been met. Therefore, we decided that the Plan 
does not have to pre-approve anticancer treatment with Abraxane (J9264) and Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 24, 2023, billed 
with procedure code G0127-59. 
 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 documentation does not support the billed code. 
 
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 G0127-59 is a column II code to column I code 11720; however, 
G0127-59 was billed with a modifier.  
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that modifier 59, XE, XP, XS, or XU shall 
not be used to bypass the edit if these 2 procedures are performed on the same distal phalanx, including the skin 
overlying the distal interphalangeal joint. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 24, 2023, billed with procedure code 
G0127-59.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that a facet joint 
injection is not medically necessary. 
 
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 injection. Our reviewer says that a 
facet joint injection is medically necessary. Our physician reviewer found that the enrollee received and 
epidural steroid injection to treat the radiculopathy. Therefore, the enrollee meets the LCD coverage criteria for 
a diagnostic block. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve a facet joint injection.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related 
supply allowance. 
 
You asked the Plan to pre-approve the CGM and related supply allowance. You say that the CGM is necessary 
because you need to monitor your sugar during the night. The Plan denied your request. The Plan says the 
Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and related supply allowance. 
Our reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM requires insulin use or low blood sugars. We are not told of low blood sugars though the 
enrollee is on Glipizide that can cause low blood sugars. Although a CGM may help this enrollee, the coverage 
criteria are not met based on the data provided. 
 
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 CGM and related supply allowance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related supply 
allowance.
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. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B 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 
criteria for coverage have not been met. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. Our reviewer also found that there is no documentation provided indicating that the Plans 
required drugs 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 (J2777).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
August 23, 2023. 
 
You asked the Plan to pay for procedure codes 88342 and 88341. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 88342 is 
bundled into payment for code 88187. Additionally, code 88341 is an add-on code to 88342 and as 88342 is not 
covered, payment cannot be made for 88341. 
 
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 88342 
is a column II code to column I code 88187. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, code 88341 is an add-on code to 88342 and as 88342 is not covered, payment 
cannot be made for 88341. 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 codes 88342 and 88341 billed for date 
of service August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections (64493 and 64494). 
 
You asked the Plan to pre-approve the services. You say that the injections are necessary to treat your pain. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested procedure to be 
approved. 
 
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 services. Our physician reviewer 
found the enrollee does not meet LCD L35936 criteria as there is no documentation of why the enrollee is not a 
candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device). 
Moreover, the last injection if viewed as therapeutic and not diagnostic and did not provide consistent relief for 
at least three (3) months.  
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 pre-approve repeat facet joint injections (64493 and 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve the service. You say that the enrollee meets the criteria necessary for the 
requested procedure to be approved. The Plan denied your request. The Plan says the procedure requested does 
not meet the criteria necessary for approval. 
 
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 service. Our physician reviewer 
found the LCD requires documentation of 3 positive diagnostic maneuvers; however, this is not documented 
and is deemed not medically reasonable and necessary at this time.  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sacroiliac joint injection (27096).
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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 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 continued inpatient hospital stay. 
 
You asked the Plan to pre-approve continued inpatient hospital stay. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
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 continued inpatient hospital stay. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee was evaluated and admitted on 
December 19, 2023 after a mechanical fall at home. The enrollee presented with right hip pain. The evaluation 
revealed minimally displaced fractures of the right inferior and superior rami. The enrollee was admitted for orthopedic evaluation, pain control and therapy services. The enrollees condition stabilized and improved. 
Beginning December 24, 2023, the enrollee was hemodynamically stable and tolerating an oral diet. The 
enrollee had participated in therapy services and was awaiting admission to a SNF. The enrollees care could 
have been safely provided in an alternative 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 continued inpatient hospital stay have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued inpatient hospital stay.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the respiratory assist device (E0470) provided from June 25, 2023, to 
July 24, 2023. 
 
You asked the Plan to pay for the respiratory assist device (E0470). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. The Plan has not provided sufficient evidence to show that Medicare criteria has 
not been met. The Plan has not disclosed if the enrollee was given a purchase option in the 10th month or if the purchase option was exercised or not. Therefore, we decided that the Plan has to pay for the respiratory assist 
device (E0470) provided from June 25, 2023, to July 24, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 20, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on July 16, 2023. 
 
You asked the Plan to waive the copayment for the MRI. You say that the copayment is excessive. 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 $325 
copayment for outpatient diagnostic test, including an MRI.  
 
You have been asked to pay a $325 copayment for the MRI. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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 MRI provided on July 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit with this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose 
monitor (CGM).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary for the enrollee's 
condition and situation. The Plan denied your request. The Plan says there is no evidence to show that the 
enrollee has tried and failed, or has a contraindication to, the Plan's preferred alternatives; Infed (iron dextran) 
and Venofer (iron sucrose). 
 
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 Injectafer. Our reviewer says that the 
Plan's criteria for coverage of Injectafer have not been met in this case. Our physician reviewer found the Plan 
requires a trial of drug Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the plans required drug(s) 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 82 units of procedure code 95004 rendered on August 7, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support that the excess units were provided. 
 
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 95004 is "Percutaneous tests (scratch, puncture, prick) 
with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of 
tests." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a request for 82 units of the CPT 
code 95004 was requested; however, the MUE is 80. The remaining 2 units were not clearly documented as 
having been actually rendered. The histamine and saline controls cannot be considered allergy testing units. 
Therefore, without sufficient support for this request, the remaining 2 units of 95004 will be considered not 
medically necessary in this case. 
 
We looked at this coder'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 82 units of procedure code 95004 rendered on August 7, 2023.