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

 
We decided that the Plan does not have to pre-approve proton beam therapy (77523). 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found treatment guidelines do not consider proton therapy for prostate cancer to be 
experimental; however, any potential benefit or detriment of proton therapy over standard intensity-modulated 
radiation therapy (IMRT) is an investigational question being pursue by clinical trials. IMRT with or without 
image-guide radiation therapy (IGRT) are also highly effective and well tolerated. To date, there are no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77523).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal cannula billed with code A4615 and pulse oximetry 
billed with code A0999 for November 29, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules say that all items and services associated with an ambulance 
transport are covered in the ambulance payment. 
 
The file shows that procedure code A4615 was billed with place of service code 41 for ambulance. This item is 
not covered when billed to this place of service, which is outside of the home. Code A0999 is covered by the 
ambulance payment and not separately paid. Therefore, we decided that the Plan does not have to pay for the 
nasal cannula billed with code A4615 and pulse oximetry billed with code A0999 for November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-home physician services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee apparently lives in an assisted living facility, where she is seen by a group that provides 
in-home visits. While care may be required on a periodic basis, there is no documentation to show why care 
should be pre-approved. The enrollee can be seen when problems arise, and the services should be billed as 
appropriate/provided at that 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve in-home physician services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests are not included in 
the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on August 25, 
2022, to August 27, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that medical criteria was established. The 
Plan denied your request. The Plan says the inpatient stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was stable enough to transfer to a participating facility for 
observation/admission level of care services after the emergency room evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on August 25, 2022, to August 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT Peripheral Nerve Stimulation (PNS). 
 
You asked the Plan to pre-approve SPRINT PNS. 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 payment may be made under the prosthetic device 
benefit for implanted peripheral nerve stimulators. 
 
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 SPRINT PNS. Our reviewer says that the services are not medically necessary. Our physician reviewer found the SPRINT PNS device is 
experimental for knee pain. 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 SPRINT PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SPRINT Peripheral Nerve Stimulation (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) Mis 
Receiver. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM Receiver. You say that you disagree with the denial. 
The Plan denied your request. The Plan says a CGM is not covered under Medicare if the enrollee is not on 
insulin or does not have documentation of recurrent problematic hypoglycemia. The enrollee does not meet 
these criteria. 
 
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 have diabetes, 
use insulin or have a history of problematic hypoglycemia Based on this information, we decided that Medicare 
rules for coverage of a Dexcom G6 CGM Receiver have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) Mis Receiver.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289, C2624). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication of a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289, C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99203, 99204, 99205, 99213, 99214, 
99215) to be provided out of area, by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that there are no other providers near the enrollee's 
area that can do the liver transplant. The Plan denied your request. The Plan says the records received do not 
indicate that the enrollee has an emergent or urgent medical condition or is in need of specialized service(s) 
that are not available in the network. The enrollee must receive services from an in-network provider. There are 
in-network providers within a reasonable distance from your location that can provide this service or item. 
 
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 
office visits (99203, 99204, 99205, 99213, 99214, 99215) to be provided out of area, by an out-of-network 
(OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane.  
You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied 
your request. The Plan says a trial of Synvisc,Synvisc One or Orthovisc 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 Durolane. Our reviewer says that 
Durolane is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they might be unsafe or ineffective 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Welireg. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says drugs covered under the pharmacy benefit are not eligible for coverage 
under the Part B benefit. The Plan also says that coverage has been approved under the pharmacy (drug) 
benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Welireg.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (Q4010) provided on October 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 Q4010 is "Cast supplies, short arm cast, adult (11 years 
+), fiberglass". 
 
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 use of code Q4010 is 
not supported by the records provided. Our reviewer found that the reported HCPCS code cannot be verified, as 
documentation does not support "fiberglass, short arm cast", as this description is not documented in the medical record, and therefore cannot be verified. 
 
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 the services (Q4010) provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 75625 and 75710 rendered on November 13, 2022. 
 
You asked the Plan to pay for the services. You say that the attached medical records should be reviewed. The 
Plan denied your request. The Plan says that the denied codes are not supported in the records submitted. 
 
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 
the denied codes is: 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 documentation supports that the 
services in question were both rendered and are separately billable from the intervention code. Diagnostic 
angiography is separately billable and not bundled in the intervention code if no recent angiography was 
performed/available or if there was a change in condition and there is satisfactory documentation of the 
angiographic findings.  In this case the enrollee has a foot ulcer and there is no suggestion that previous 
angiography was performed. Additionally, the results of angiography at both the aorta and right lower 
extremity are satisfactorily described to justify billing of the supervision and interpretation codes, specifically 
75625 (aorta) and 75710 (unilateral extremity).  
 
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 codes 75625 and 75710 rendered on November 13, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary cap 245mg. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs the medication as it is a 
continuation of therapy. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rytary cap 245mg.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L1 and L2 kyphoplasty. You say that you want the Plan to approve the 
services. The Plan denied your request. The Plan says imaging shows mild to moderate disc bulge, moderate to 
severe facet osteoarthritis, and mild ligamentum flavum hypertrophy throughout the lumbar spine that indicate 
the enrollee's pain is not primarily due to the identified subacute vertebral compression fractures. Computed 
tomography of the lumbar spine shows L1 and L2 fracture retropulsion. These are exclusion criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L1 and L2 kyphoplasty. Our reviewer 
says that the enrollee does not meet coverage criteria. Our physician reviewer found the provided diagnostic 
imaging studies indicated that the compression fracture at L1 is chronic. Additionally, the pain is not 
documented to be worsening. There is no indication of progression of vertebral body height loss, greater than 
25% body height reduction, kyphotic deformity, or a severe impact of vertebral fractures on her daily 
functioning. Moreover, the May 17, 2023, computed tomography scan is noted to show stable subacute 
compression fracture of L2 with mild retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 and L2 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L2 kyphoplasty (22514, 22515).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory test (0112U) provided on July 20, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that these laboratory services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that this claim cannot be paid 
because the number of anesthesia minutes has not been provided. 
 
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. Specifically, the laboratory services at issue are not related to anesthesia. The 
Plan has not provided a relevant argument for denial in this case, nor has their reasoning been supported with 
documentation. Therefore, we decided that the Plan has to pay for the laboratory test (0112U) provided on July 
20, 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.