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

 
We decided that the Plan does not have to pre-approve tbo-filgrastim (Granix). 
 
You asked the Plan to pre-approve tbo-filgrastim (Granix). You say that the requested tbo-filgrastim (Granix) 
is medically necessary. The Plan denied your request. The Plan says the requested tbo-filgrastim (Granix) is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 tbo-filgrastim (Granix). Our reviewer 
says that the requested tbo-filgrastim (Granix) is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of neutropenia secondary to immunosuppressive therapy 
following kidney transplantation. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug formulation in the enrollee's clinical situation.  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 tbo-filgrastim (Granix) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tbo-filgrastim (Granix).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an oxygen concentrator. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says you must receive care and services from a 
network provider. OON services are not a covered benefit when services are available within your plan. 
 
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 
an oxygen concentrator (E1390) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary due 
to your complex medical needs. The Plan denied your request. The Plan says your records do not show the 
unique continued treatments and care that you need can only be given in a hospital setting. 
 
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 you appear to have a poor prognosis and are not expected to improve with long term 
acute care services. You only require short term additional acute care hospital services that can safely be 
provided at the current facility until more appropriate for transfer to a lower level of care soon. You do not 
require services at the LTACH that are not already available at the current facility.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) 
rendered on February 28, 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 Current Procedural Terminology (CPT) code 99214-25 (1 unit) remains 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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 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 the documentation does not 
support this level of coding. Medical decision making of moderate complexity requires 2 out of 3 of multiple 
diagnoses or management options, a moderate amount and complexity of data reviewed and a moderate risk of 
complication. The provided records in this case do not document 2 out of 3 of multiple diagnoses or 
management options, a moderate amount and complexity of data reviewed and a moderate risk of complication. 
Additionally, the provided records in this case do not document 30-39 minutes of time spent on this service. 
 
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 evaluation and management services (procedure code 99214) rendered on February 28, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 28, 2023, to  
May 18, 2023.  
 
You asked the Plan to pay for the psychotherapy. You say that you were told you could use an out-of-network 
provider. The Plan denied your request. The Plan says this type of provider is not part of the Medicare 
program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from April 28, 2023, to 
May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inspan device as a part of lumbar instrumentated 
fusion.  
 
You asked the Plan to pre-approve the Inspan device. You say that the service is medically necessary for the 
treatment of degenerative lumbar spinal stenosis as indicated by the enrollee's diagnosis and presentation.  The 
Plan denied your request. The Plan says the Inspan device as a part of lumbar instrumentated fusion is not 
medically necessary. The Plan says the device has not yet shown to be better or safer than standard procedures.  
 
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 Inspan device. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for chronic low back pain and radicular complaints. The current evidence based medical guideline and peer reviewed literature do not fully support the interspinous fusion 
device procedure over the gold standard of lumbar fusion. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed 
above. 
 
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 Inspan device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Inspan device as a part of lumbar instrumentated fusion.
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 does not has help and assistance home. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines.  
The Plan says that the services needed may be provided safely in a lower 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 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.  
 
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 pre-approve an infrared sauna. 
 
You asked the Plan to pre-approve an infrared sauna. You say that the requested sauna is medically necessary 
for your health conditions. The Plan denied your request. The Plan says there is sufficient evidence to conclude 
the use of infrared therapy devices is medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an infrared sauna have not been met. Specifically, the requested infrared sauna is not a covered 
benefit with the Plan. Therefore, we decided that the Plan does not have to pre-approve an infrared sauna.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional simple extractions (D7140 x4), an additional 
surgical extraction (D7210 x1) and injection of a therapeutic drug (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that this is a problem that needs to be addressed 
right away. You say you have sinus issues that cause terrible migraines due to the infection and breakage of 
your teeth. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. The Plan also says there is no coverage for injection of a therapeutic drug. 
 
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. These services are not covered under the medical benefit; however, the Plan offers a dental benefit in excess of 
Medicare coverage. The record shows your benefit for the requested items or services was exhausted on July 8, 
2023 when the Plan authorized eight simple extractions and three surgical extractions. In addition, there is no 
coverage for injection of a therapeutic drug. Therefore, we decided that the Plan does not have to pre-approve 
additional simple extractions (D7140 x4), an additional surgical extraction (D7210 x1) and injection of a 
therapeutic drug (D9610).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88184 billed for date of service January 5, 
2023.   
You asked the Plan to pay for procedure code 88184. You say that you have billed the services at issue 
correctly. 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 88184 is 2. The MAI value for this code is 3. You billed 10 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 88184 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88184 billed for date of service January 5, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography cerebral perfusion analysis (CTP) rendered on 
on March 17, 2023. 
 
You asked the Plan to pay for the services. You say that the medical records support the procedure that has 
been performed. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pay for the services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found that the 
exam revealed intermittent occlusion and reconstitution of several segments of the right vertebral artery and as 
such the CT perfusion study was reasonable and indicated to assess the penumbra of at-risk brain. Intermittent 
occlusion of several segments of the right vertebral artery is one of the provided indications for the CT 
perfusion study. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
computed tomography cerebral perfusion analysis (CTP) rendered on on March 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676, E0673, E0673, 
E0667) provided on February 15, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676, E0673, E0673, E0667) provided on February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heated humidifier (E0562) for a positive airway pressure 
device. 
 
You asked the Plan to pay for a heated humidifier. You say that you have billed the item at issue correctly. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a heated humidifier (E0562) for a positive airway pressure 
device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585).  
You asked the Plan to pre-approve Botox. You say that the requested treatment is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for treatment with Botox have not 
been met. 
 
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 Botox have been met. Specifically, the 
provided records do not contain a complete description of the site(s) injected. Therefore, we decided that the 
Plan does not have to pre-approve treatment with Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and appliance (E0651 
and E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and appliance to be provided by an OON 
provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested items are neither emergent nor urgent to seek OON care. The Plan says there are in-
network providers available to the enrollee that can provide equivalent equipment. 
 
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 
a pneumatic compression device and appliance (E0651 and E0667) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95886 rendered on November 21, 2022. 
 
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 that Current Procedural Terminology (CPT) code 95886-26-XU (2 Units) remains 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 95886 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done 
with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, 
innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary 
procedure)." 
 
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 supported by the medical records. Our reviewer found that the intraoperative neuromonitoring 
interpretive report cites an EMG (electromyography), along with direct nerve stimulation was performed on the 
lower extremities at bilateral quadriceps, tibialis anterior, gastrocnemius, and adductors. As the testing was 
performed bilaterally, the documentation does support CPT 95886 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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 95886 rendered on November 21, 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.