Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift (E0630) provided on September 18, 2022. 
 
You asked the Plan to pay for the lift. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims lines billed with codes without a KX, GA 
or GZ modifier will be rejected as missing information.  
 
We looked at the file and Medicare rules. In this case, code E0630 was billed without modifier KX, GA, or GZ, 
as required by LCA A52516. Based on this information, we decided that Medicare rules for coverage of the lift 
have not been met. Therefore, we decided that the Plan does not have to pay for the patient lift (E0630) 
provided on September 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over the counter (OTC) COVID-19 test purchased while 
traveling outside of the country on September 6, 2022. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you were required to take a COVID-19 
test prior re-boarding your cruise. The Plan denied your request. The Plan says this test is not covered because 
it was not related to emergency or urgently need medical care. 
 
The Plan must follow Medicare rules. Medicare rules say that worldwide coverage applies to emergency or 
urgently needed medical services.  
 
We looked at the file and Medicare rules. In this case the COVID-19 test was purchased outside of the United 
States. This test does not qualify as emergency or urgently needed medical care. Based on this information, we 
decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for the over the counter (OTC) COVID-19 test purchased while traveling 
outside of the country on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro device (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the MyoPro meets, but does not exceed, the 
enrollee's medical need. The Plan denied your request. The Plan says there is not enough medical evidence that 
shows the MyoPro is reasonable and necessary to improve the function of the enrollee's right arm. 
 
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 MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro in matched controlled studies has not been shown to reliably impact 
function especially 7 years after a stroke. Randomized controls have failed to show significant impact. Our 
reviewer found that the enrollee's left arm is impacted. It is not clear how much improvement can be expected 
with their function as they have likely developed strategies over the years and how much the MyoPro would 
add over current function or standard orthosis is not presented. Our physician reviewer also found that it is not 
medically necessary as it is not standard medical practice, does not reliably meet the enrollee's needs, and there 
is no evidence the enrollee requires the device to meet their needs.  
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) coverage. 
 
You asked the Plan to pre-approve SSBCI coverage. You say that you have chronic obstructive pulmonary 
disorder (COPD.) You say that the medical records provided support your qualifying for SSBCI coverage. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for expanded benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI coverage. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found that the criteria for SSBCI 
includes the patient requiring intensive care management, high risk for hospitalization, and the condition must 
be life-threatening or significantly limit their overall health or function. However, the provided documentation 
described the enrollee as stable on current treatment by their physician. There is no documentation of the 
enrollee requiring intensive care or of a life-threatening status of her conditions 
 We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SSBCI have not been met. Specifically, we have confirmed that you do not 
have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does 
not have to pre-approve special supplemental benefit for the chronically ill (SSBCI) coverage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve Opzelura. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Opzelura.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on September 19, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the records show a previous 
visit on August 10, 2022 with the same physician group. Based on this information, we decided that Medicare 
rules for coverage of the office visit have not been met.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on September 19, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission for an arthroplasty 
procedure. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee's life is severely 
affected by the ongoing knee pain she is suffering with day after day. There are additional medical records 
attached. The Plan denied your request. The Plan says the request for approval of an inpatient hospital 
admission for a left total knee replacement does not meet the requirements for approval. This surgery is usually 
performed as an outpatient procedure. 
 
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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are 
met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for elective 
total knee arthroplasty. The record provided does not indicate that the treating physician has a reasonable 
expectation at the time of admission of a length of stay spanning 2 or more midnights, considering complex 
medical factors. The initial day may be spent in observation until it is clearly expected that a second midnight 
would be required, at which time the physician may order inpatient admission. The elements of the coverage 
criteria are not satisfied. The requested service is not 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 an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission for an arthroplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the requested SBRT is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the SBRT request in this scenario is palliative and 
considered not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that SBRT is not considered medically necessary when 
the tumor burden cannot be completely targeted with acceptable risk to critical normal structures. 
 
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 SBRT. Our reviewer says that the 
requested SBRT is not medically necessary. Our physician reviewer found the guidelines indicates that SBRT 
is only necessary if it can be safely delivered when encompassing all sites of disease. The reviewer found that 
the provided documentation indicates the enrollee has a multitude of liver metastases thus making it not 
feasible to encompass all sites of disease as required in the guidelines. Therefore, the reviewer found that the 
requested SBRT is not medially 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 SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cognitive therapy provided by an occupational therapist on 
October 1, 2021, to October 19, 2021. 
 
You asked the Plan to pay for the cognitive therapy services. You say that the codes billed are appropriate and 
the claim should be processed for payment. The Plan denied your request. The Plan says the clinical 
information received do not show any acute acquired cognitive deficits resulting from head trauma, or acute 
neurologic events including cerebrovascular accidents. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 cognitive therapy services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found that the enrollee has 
dementia, which is a chronic condition. There is no report of an acute event. The provided documentation does 
not clearly describe the patient has an acute neurological condition, qualifying her for coverage of cognitive 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the cognitive therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for cognitive therapy provided by an occupational therapist on October 1, 2021, to 
October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
(87481, 87798, 87801) provided on November 9, 2021. 
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says PCR testing is not indicated as the following are appropriate 
means to verify fungal infection: direct microscopic examination with potassium hydroxide, fungal culture of 
desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. 
 
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 a fungal infection PCR panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current standard of care for investigation of onychomycosis in a toenail is to perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, and specific. 
It is unclear as to why this enrollees fifth digit toenail needed to undergo PCR testing when other less 
expensive and efficacious lab tests are available. Therefore, the requested PCR testing of this enrollees right 
fifth digit toenail was 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 a fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel (87481, 87798, 87801) 
provided on November 9, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Select MDx for prostate cancer (0339U) provided on November 16, 
2022. 
 
You asked the Plan to pay for Select MDx for prostate cancer. You say that this test was medically reasonable 
and necessary. The Plan denied your request. The Plan says that the criteria for coverage of this test are not 
met. 
 
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 pay for Select MDx for prostate cancer. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the criteria for coverage of this test are 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 Select MDx for prostate cancer have been met. Therefore, we decided that the 
Plan has to pay for Select MDx for prostate cancer (0339U) provided on November 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 14, 2022, to 
August 18, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says the enrollee showed 
appropriate infection responses including a fever, mild tachycardia and leukocytosis. There is no evidence of 
hypotension or organ failure. As such, the diagnosis of sepsis is not supported. 
 
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 A41.53, described as sepsis, due to 
Serratia. 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 at the DRG originally 
billed. Our reviewer says that the documentation does not support the billed code. Our physician reviewer found the 
enrollee showed appropriate infection responses including a fever, mild tachycardia and leukocytosis. There is no 
evidence of hypotension or organ failure. As such, the diagnosis of sepsis is not supported. 
 
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 
inpatient hospital services provided on August 14, 2022, to August 18, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 14, 2022, to 
May 16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code U07.1, described as 
COVID-19. 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 at the 
DRG originally billed. Our reviewer says that documentation does not support the billed code. Our physician 
reviewer found the medical record documentation indicates that the enrollee was admitted for a urinary tract 
infection. The enrollee was noted to be swabbed for COVID-19 prior to leaving the skilled nursing facility and 
tested positive. The documentation stated, she had a normal pulmonary effort with normal breath sounds and 
no wheezing or rales.  
 
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 inpatient hospital services provided on May 14, 2022, to May 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that this regimen has become the standard of care 
for treatment of the enrollee's condition and overall survival beats any bortezomib-featured regimen. The Plan 
denied your request. The Plan says the Plan requires a trial of Velcade before it will approve Darzalex Faspro. 
 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 Darzalex Faspro. Our reviewer says 
that the enrollee does not meet criteria for a step therapy exception for Darzalex Faspro. Our physician 
reviewer found the enrollee has not tried and failed the Plan's preferred drug of Velcade. The record does not 
show that this drug would likely be less effective and/or have adverse effects 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 Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of Darzalex Faspro.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87801, 87150, 87641, 87798) provided on July 
27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
payable. 
 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 87801 is "Infectious agent detection by nucleic acid 
(DNA or RNA), multiple organisms; amplified probe(s) technique". 
 
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 87801 is 
not supported by the records provided. Our reviewer found that this test examines a specimen from a direct 
source such as sputum, fluid from chest, throat swab or nasal washings. These specimens were not given. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87801 have not been met. 
 
In this case, we have confirmed that code 87150 a column II code to column I code 87500. We have also 
confirmed that codes 87798 and 87641 are column II codes to column I code 87801. This claim has not been 
billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the services (87801, 87150, 
87641, 87798) provided on July 27, 2022.