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

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 6, 2023, 
to June 17, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 6, 2023, to June 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0835) and 
additional items and accessories (codes E2361, E1028, E2615, E0955, E1028, E2605, and E1002). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair (K0835) and additional items and 
accessories. You say that the client resides in a SNF, and you need a Prior Authorization Denial in order to 
pursue their secondary insurance that requires a formal denial from the primary insurance. The Plan denied 
your request. The Plan says this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   
Records show that a group 2 standard power wheelchair (K0835) and additional items and accessories is being 
requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 standard power wheelchair (K0835) and additional items and accessories (codes E2361, E1028, E2615, 
E0955, E1028, E2605, and E1002).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Eylea HD (J3590). 
 
You asked the Plan to pre-approve Eylea HD. You say that this is not for the enrollee's convenience. The 
enrollee's condition is worsening. The Plan denied your request. The Plan says that the requested services are 
not reasonable and necessary. 
 
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 Eylea HD. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has a diagnosis of exudative age-related 
macular degeneration with active choroidal neovascularization. The Food and Drug Administration has stated 
that the requested drug is indicated for the treatment of neovascular (wet) age-related macular degeneration. 
The elements of the coverage criteria are satisfied, and the requested service is 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 Eylea HD have been met. Therefore, we decided that the Plan has to pre-
approve Eylea HD (J3590).  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain strength in order to 
return to her assisted living facility. The Plan denied your request. The Plan says the enrollee does not require 
inpatient rehabilitation facility services. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found The Plan erred in its denial of the IRF admission. Per Medicare Benefit Policy Manual Ch 1, 110, and 42 
CFR 412.622, the medical record complies with the various documentation requirements for IRF admission. 
The enrollees condition is in fact complex given their cycle of repetitive injury. There is every reason to 
expect that they will participate in and benefit from IRF level services. Therefore, the requested inpatient 
rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the device is used to treat COPD. The Plan denied your request. The Plan says that you have not been using the ventilator adequately.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a home ventilator. Our Medical Director states that you have a listed diagnosis of chronic respiratory failure consequent to COPD. A device mode of AVAPS-AE was ordered, with the device to be used during sleep and as needed while awake. Products classified as HCPCS code E0466, when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in the Medicare RAD policy will be denied as not reasonable and necessary. Our Medical Director found that your condition does not meet Medicare criteria for 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, cleaning, oral hygiene instructions 
provided on March 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your claim for reimbursement was not filed 
timely. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The records 
provided show that the claim for payment was submitted on July 13, 2023. This is more than 120 days from 
March 6, 2023. Therefore, the rules for coverage have not been met and the Plan does not have to pay for a 
periodic oral evaluation, cleaning, oral hygiene instructions provided on March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-
network (OON) provider.  
 You asked the Plan to pre-approve endocrinology services. You say that you need to see an endocrinologist as 
soon as possible. The Plan denied your request. The Plan says that the service requested may be provided by a 
participating 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 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 
endocrinology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you would like this 
request to be reconsidered as it is quite a distance from your apartment to your car and back again. You also 
say that you would love to have a scooter available inside your apartment to help you get around. The Plan 
denied your request. The Plan says this request is not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a group 1 standard power operated 
vehicle have been met. Specifically, the provided records do not show documentation of a home assessment to 
determine the utility and safety of a power operated vehicle in your home. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. 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. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires low blood sugars or insulin use. This enrollee is not taking insulin and is not on medications that do 
not cause low blood sugars. We are not told why the enrollee cannot use a fingerstick meter instead; hence, the 
coverage criteria are not 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. 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 an office visit provided 
on June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hysterectomy. 
 
You asked the Plan to pre-approve a total hysterectomy. You say that a total hysterectomy is medically 
necessary per the medical records submitted. The Plan denied your request. The Plan says a total hysterectomy 
for perineal and pelvic pain is considered medically necessary when there is documentation of current cytology 
results and evidence that conservative measures have been unsuccessful in managing pain. Based on the 
clinical documentation provided there is no documentation of any conservative treatment of your perineal and 
pelvic pain. 
 
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 total hysterectomy. Our reviewer says 
that the requested total hysterectomy is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided there is no documentation that the total 
hysterectomy at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe 
and effective for the patient. As summarized in Up to Date, Hysterectomy (benign indications): Selection of 
surgical route: "Rationale for hysterectomy - The reason for the hysterectomy, risks and benefits of the 
procedure, alternatives, and expectations for outcome should be discussed with the patient in detail. Since a 
number of the indications for hysterectomy are based more upon opinion than evidence from well-designed 
studies, informed consent with thorough exploration of patient preferences and expectations is particularly 
important. In the absence of a life-threatening emergency (e.g., uterine hemorrhage), the decision to proceed 
with hysterectomy is made mutually by the patient and her clinician based upon her functional impairment, 
childbearing plans, response to medical therapy, discussion of alternatives, and perception that the risks of the 
procedure are outweighed by the expected benefits." The provided records in this case do not document a 
discussion between the provider and the patient of the risks and benefits of the procedure, alternatives, and 
expectations for outcome; the records do not document the patient's response to medical therapy.  
 
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 total hysterectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hysterectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMS was approved by the 
Food and Drug Administration in 2014. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in the enrollee's clinical management.  
We looked at this physician'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 pre-approve a CardioMEMS Heart Failure (HF) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 14, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aveed. 
 You asked the Plan to pre-approve Aveed. You say that Aveed is medically necessary. The Plan denied your 
request. The Plan says a trial of injectable testosterone is required before alternatives can be considered. 
 
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 Aveed. Our reviewer says that Aveed is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug or 
any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aveed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Aveed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 26, 2023, billed with codes 
87481, 87500, 87640-59, 87641, 87653, & 87798. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. 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 a 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 lab testing billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on April 26, 
2023, billed with codes 87481, 87500, 87640-59, 87641, 87653, & 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo System. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of device has not been proven to be helpful. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollees clinical 
management.  
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo System.