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

 
We decided that the Plan does not have to pre-approve Panzyga for the enrollee. 
 
You asked the Plan to pre-approve Panzyga. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documented trial and failure of, or contraindication to Gamunex-C. 
 
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 Panzyga. Our reviewer says that 
Panzyga is not medically reasonable and necessary. The clinical documentation does not support that 
Gamunex-C has been tried and failed. The clinical documentation does not support that Gamunex-C would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician 
reviewer found that the enrollee's condition does not meet step therapy criteria for Panzyga. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Panzyga have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Panzyga for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for acupuncture treatment provided from December 6, 2021, to 
December 17, 2021. 
 
You asked the Plan to reimburse you for the acupuncture treatment. You say that you have been unsuccessful 
in your attempts to contact this provider, who does his own billing, to submit the claims to the Plan with any 
correction to the codes. You say this provider's office is closed indefinitely and you have no way to contact 
him. The Plan denied your request. The Plan says that a corrected claim is needed with an updated diagnosis 
code. 
 
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 Plan has not provided us with the correct diagnosis codes and 
the coding rules to support the denial. Therefore, we decided that the Plan has to reimburse you acupuncture 
treatment provided from December 6, 2021, to December 17, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular microscope diagnostic system (MMDx) testing 
(0087U) provided on February 2, 2022. 
 
You asked the Plan to pay for MMDx testing. You say that this test was medically necessary and is covered by 
Medicare. The Plan denied your request. The Plan says this test was not billed in accordance with Medicare 
rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of MMDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for molecular microscope diagnostic system (MMDx) testing 
(0087U) provided on February 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc, Syncivc, or Synvisc-one. 
 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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Orthovisc, Syncivc, or Synvisc-one. The 
reviewer found that the documentation does not support that Orthovisc, Synvisc, or Synvisc-one would likely 
be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer 
found that the step therapy criteria have not been 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 
discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, 
biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of 
the rotator cuff, subacromial bursa, foreign body[ies]) (procedure code 29822) provided to the enrollee on 
December 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for as it was separate and distinct. 
The Plan denied your request. The Plan says this code should not be unbundled. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 not supported by the medical records. Our physician reviewer found that the 
operative report describes rotator cuff with limited debridement left shoulder. In this case, per the National 
Correct Coding Initiative (NCCI) Policy Manual limited debridement is considered inclusive to the primary 
procedure, and therefore this procedure cannot be verified.  
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 pay for arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral 
bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor 
complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial 
bursa, foreign body[ies]) (procedure code 29822) provided to the enrollee on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (J2506). 
 
You asked the Plan to pre-approve Neulasta. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not being prescribed for a 
medically-accepted indication. 
 
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 Neulasta. Our reviewer says that the 
requested drug, Neulesta, is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee is receiving a chemotherapy regimen with a high risk of 
febrile neutropenia or that he is receiving a chemotherapy regimen with an intermediate risk of febrile 
neutropenia with additional risk factors such as age over 65, poor performance status, poor nutritional status 
and prior neutropenia. Therefore, the reviewer found that Neulesta is not medically reasonable and necessary in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve Neulasta (J2506).
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 you are requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says the enrollees needs can be met at a lower level of care 
such as skilled nursing facility (SNF). 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve right robot assisted Mako total knee arthroplasty with computed 
tomography (CT) of the right knee for the eenrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical studies do not support the use of a computed tomography (CT) scan to plan 
for knee replacement surgery, unless the x-rays show certain abnormal findings. 
 
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 pre-approve the services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that if the MAKO 
robotic assisted total knee replacement is approved the requested CT of the right knee is necessary as part of 
the planning of the procedure and necessary for the device software. 
 
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 pre-
approve right robot assisted Mako total knee arthroplasty with computed tomography (CT) of the right knee for 
the eenrollee.  
 
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 wig provided on September 28, 2020. 
 
You asked the Plan to pay for the wig. You say that the requested wig was medically necessary due to your 
having a brain tumor. You say that you endured radiation treatment where you lost your hair. The Plan denied 
your request. The Plan says Medicare does not provide coverage for wigs. The Plan says that the supplemental 
wig benefit they offer has been exhausted. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan offers its own coverage for wigs, wig stands, and adhesive up to a maximum 
of $300 in a lifetime. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan's supplemental benefit for coverage for a wig, shows 
to have been exhausted. The records provided show that the Plan has paid $300 toward the cost of a wig for 
you within your time as a member of their Plan. Therefore, we decided that the Plan does not have to pay for a 
wig provided on September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from October 14, 
2020, to October 16, 2020, billed with diagnosis related group (DRG) code 308. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 308. You say that the enrollee's 
altered mental status was due to metabolic encephalopathy. The Plan denied your request. The Plan says DRG 
308 is not supported as the diagnosis of Metabolic encephalopathy. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, G93.41, defined as 
Metabolic encephalopathy. 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 inpatient 
hospital services billed with DRG 308. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found the medical records did not support the billing of Metabolic encephalopathy with 
DRG 308.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from October 14, 2020, to October 16, 2020, billed with diagnosis 
related group (DRG) code 308.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene analysis (hereditary cancer 
screening) (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that you have an extensive family history of breast 
cancer, and this test is medically necessary. The Plan denied your request. The Plan says this test is only 
covered for people who have a personal history of breast, ovarian or pancreatic cancer. If you only have a 
family history of cancer, this test is considered a screening which is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, hereditary cancer gene analysis is being requested solely for screening purposes 
as you do not have a personal history of cancer. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene analysis 
(hereditary cancer screening) (81162).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted supplies and materials used in non-surgical 
procedures (99070) provided November 2, 2021 to February 9, 2022 
 
You asked the Plan to pay for the unlisted services. You say that the office already has all of your documents 
regarding your hormone replacement therapy. The Plan denied your request. The Plan says an itemized bill was 
requested and not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 unlisted supplies and materials used in 
non-surgical procedures (99070) provided November 2, 2021 to February 9, 2022 have been met. An itemized 
bill was requested from the provider. The Plan made several attempts to obtain the additional records without success. Therefore, we decided that the Plan does not have to pay for unlisted supplies and materials used in 
non-surgical procedures (99070) provided November 2, 2021 to February 9, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast mammography provided on July 6, 2021. 
 
You asked the Plan to pay for a breast mammography. The Plan denied your request. The Plan says this claim 
is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on September 30, 2021. Comparison of the two claims shows these are exact duplicates. There is 
no evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for a breast mammography have not been met. Therefore, we 
decided that the Plan does not have to pay for a breast mammography provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xT Solid Tumor and Heme comprehensive testing panel 
(81455) billed for date of service April 9, 2022. 
 
You asked the Plan to pay for the comprehensive testing panel. You say that this test was medically necessary 
and was reported correctly. The Plan denied your request. The Plan says that this claim was billed with an 
incorrect date of service as the reported date must be the date the specimen was collected. 
 
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 rules also say that generally laboratory services should be reported with the date of the specimen 
collection as the date of service. However, there are three exceptions to this rule. 
 
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 Plan has not acknowledged nor discounted the exceptions to the 
rule applied in their decision to deny this claim. Based on the documentation provided, it appears that this 
claim is for testing which was performed on a tumor specimen which was collected in a hospital setting. It 
appears that this collection was provided during a procedure, and it would have been inappropriate to collect 
this sample outside of this procedure. It also appears that the results of this test were not necessary to influence 
the hospital care at the time of collection. This means that an exception to the rule has been met, and the correct 
date of service would be the date the test was performed. Therefore, we decided that the Plan has to pay for 
Tempus xT Solid Tumor and Heme comprehensive testing panel (81455) billed for date of service April 9, 
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 pay for the compounded drug rendered on March 11, 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 procedure code J7999 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 J7999 is compounded drug, not otherwise classified. 
 
We find that CPT code J7999 is not supported in the medical record. Specifically, the records do not support 
the number of units billed. 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 pay for the compounded drug 
rendered on March 11, 2022.