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

 
We decided that the Plan does not have to pay for code J3490 for date of service October 31, 2022. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as a minor surgery procedure. This means this code is included in the global surgery 
period of the surgery services. Without an appropriate modifier, the claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of code J3490 have not been met. Therefore, we 
decided that the Plan does not have to pay for code J3490 for date of service October 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve  6 office visits and treatment with an out-of-network (OON) 
general surgery provider. 
 
You asked the Plan to pre-approve  the 6 office visits and treatment with an OON general surgery provider. 
You say that surgery with the OON provider is likely to lead to a better medical outcome and ultimately could 
be less costly.  The Plan denied your request. The Plan says that they have in-network general surgeons who 
are available for possible resection of pancreatic adenocarcinoma if that becomes a feasible possibility in the 
future.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 6 office visits and treatment with an 
OON general surgery provider. Our reviewer says that the criteria for coverage of OON care have been met. 
Our physician reviewer found the enrollee has complex pancreatic head cancer which is involving the superior 
mesenteric vein (SMV.) This is very complex, challenging surgery to undergo if feasible and should be performed by a surgical oncologist with pancreatic and biliary resection experience. Surgical outcomes are 
reported to be higher at facilities with dedicated team to perform Whipple procedures. It is unclear that any 
general surgery provider (in network) could provide equivalent surgical treatment. Out of network 
considerations should be allowed to provide this with the most experienced pancreatic surgeon, given that 
overall outcomes are shown to be better at higher volume centers with higher volume providers. 
 
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 6 office visits and treatment with an OON general surgery provider have 
been met. Therefore, we decided that the Plan has to pre-approve  6 office visits and treatment with an out-of-
network (OON) general surgery provider.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis, sacroiliac joint injection. 
 
You asked the Plan to pre-approve a surgery procedure. You say that the enrollee had excellent response to 
sequential sacroiliac injections. The Plan denied your request. The Plan says this procedure is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a surgery procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented sacroiliac joint instability, fracture, or lesion. 
 
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 surgery procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an arthrodesis, sacroiliac joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7310, D7311), and inhalation of nitrous 
oxide (D9230). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to approve the services. 
The Plan denied your request. The Plan says the requested services are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty (D7310, D7311), and inhalation of nitrous oxide (D9230).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) 
provided on February 2, 2022. 
 
You asked the Plan to pay for the fluoroscopic guidance. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says the original determination was correct.  
 
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 fluoroscopic guidance. Our reviewer says that the fluoroscopic guidance is not considered medically reasonable and necessary in this case. Our 
physician reviewer found ultrasound guidance, fluoroscopic guidance, and knee arthrography for knee 
injections, including for hyaluronic acid derivative administration, are considered experimental. Therefore, the 
reviewer found that the fluoroscopic guidance is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the fluoroscopic guidance have not been met. Therefore, we decided that the 
Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) provided on February 2, 
2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427, A0425) provided on October 10, 2022. 
 
You asked the Plan to pay for ambulance services. You say that payment is due for these services. The Plan 
denied your request. The Plan says that the primary payer paid more than the Medicare allowed amount for 
these services, so no additional payment is due. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare secondary payment amounts are 
determined by a formula and are the lowest of three options. 
 
We looked at the file and Medicare rules. In this case, the providers actual charge is $2,028.10, the primary 
payer paid $1,028.10, the Medicare fee schedule allowed amount in this case is $628.64, and the Plans 
required cost-share amount for covered ambulance services is $290. This means that for option one (the Plan 
pays the actual charge less the primary payment), the Plan payment would be $1,000. For option two (the fee 
schedule allowed amount less the Plans cost sharing), the Plan would owe $338.64. For option three, the 
Plans payment would also amount to $1,000 in this case as the primary payer has no allowable amount for this 
service. This means that according to Medicare rules, the Plan should pay $338.64 for these services, and the 
enrollee cannot be expected to pay more than the Plans allowed cost-sharing of $290. Payment made by 
another entity does not waive the Plans responsibility to make payment for covered services. Therefore, we 
decided that the Plan has to pay for ambulance services (A0427, A0425) provided on October 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Interspinous spacer device. 
 
You asked the Plan to pre-approve an Interspinous spacer device. You say that the enrollee has been dealing 
with this pain for too long and it is disrupting their quality of life. The Plan denied your request. The Plan says 
there is a lack of evidence to support interspinous spacer devices as safe and effective. 
 
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 an Interspinous spacer device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Interspinous spacer devices are experimental, and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Interspinous spacer device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Interspinous spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met in an alternate level of care.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve High Intensity-Focused Ultrasound (HIFU) Including Ultrasound 
Guidance (55880).  
 
You asked the Plan to pre-approve HIFU. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service 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 HIFU. Our reviewer says that the 
requested service is considered medically reasonable and necessary in this case. Our physician reviewer found 
High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. 
HIFU was Food and Drug Administration (FDA) approved for prostate gland ablation October 9, 2015.  HIFU 
of the prostate (CPT 55880) has Medicare coverage as of July 1, 2017. More than 100 clinical studies have 
demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side 
effects such as impotence, urinary incontinence and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have been met. Therefore, we decided that the Plan has to pre-approve 
High Intensity-Focused Ultrasound (HIFU) Including Ultrasound Guidance (55880).   
 
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: 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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for thoracic spine surgery. 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 and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L3 kyphoplasty. You say that you want the Plan to approve the service. The 
Plan denied your request. The Plan says Imaging does not document there is more than 25% vertebral body 
height reduction at L3. The enrollee does not meet inclusion criteria. MRI shows retropulsion at L3. This is an 
exclusion criterion. 
 
The Plan follows Medicare rules. 
 
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 L3 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the noted L3 compression fracture being acute or subacute. Her pain is rated at 7/10; 
however, she does not state the pain is worsening and in fact, as of her June 22, 2023, examination, the pain is 
the same. There is no corroboration of progression of the vertebral body height loss, greater than 25% vertebral 
body height reduction, Kyphotic deformity, or that the compression fracture has a severe impacted on her daily 
functioning. Moreover, the May 24, 2023, magnetic resonance imaging (MRI) demonstrated retropulsion at the 
L3 level. This is a contraindication for the requested procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 kyphoplasty (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The plan has indicated coverage for such a device is available upon request. 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an ILR. Our reviewer says 
that services are not medically necessary. Our physician reviewer found the enrollee had no history of atrial 
fibrillation, nor were any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. At this 
time, insertion of an ILR would not be considered medically appropriate 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
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 enrollee needs acute inpatient rehabilitation in 
order to return home. The Plan denied your request. The Plan says criteria for admission to the acute IRF 
setting have not been met. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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.