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

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee has tried and failed many other 
medications and needs Dupixent to keep from requiring another sinus surgery. The Plan denied your request. 
The Plan says the requested drug is not eligible for Medicare coverage. 
 
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 Dupixent.  
 
Benefits for Dupixent 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the chest (71045), 
provided on October 22, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says there is no evidence that two separate services were provided on this date of service. 
 
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 the radiologic examination (x-ray) of 
the chest (71045), provided on October 22, 2021. have been met. Specifically, there is no evidence that two 
separate services were provided on this date of service.. Therefore, we decided that the Plan does not have to 
pay for the radiologic examination (x-ray) of the chest (71045), provided on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical epidural steroid injections. 
 
You asked the Plan to pre-approve cervical epidural steroid injections. You say that you have been struggling 
to get around due to increased pain. The Plan denied your request. The Plan says there has not been a 3-month 
interval between both injections and there is no documentation of a 50% pain improvement. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are indicated when 
the ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function 
(using same scale as baseline) for at least three months. 
 
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 cervical epidural steroid injections. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee's last 
epidural injection was less than three months ago on April 25, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cervical epidural steroid injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cervical epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride treatment (D1206) you received on January 25, 
2022. 
 
You asked the Plan to pay for the fluoride treatment (D1206). You say that you would like to appeal this claim. 
The Plan denied your request. The Plan says this service is not covered under your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Only those dental codes explicitly listed in your dental benefits chart 
are covered.  The code billed for this fluoride treatment (D1206) is not listed as a covered service under your 
contract. Therefore, we decided that the Plan does not have to pay for the fluoride treatment (D1206) you 
received on January 25, 2022.
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 would greatly benefit from an IRF level 
of care to increase independence, address her respiratory needs, and provide pain control. The Plan denied your 
request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level 
of care such as at a skilled nursing facility, on an intermittent basis at home with home health care, or in a long-
term care setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no documentation that the enrollee requires the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a travel allowance provided to the enrollee on October 3, 
2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code P9603 (23 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 P9603 is "Travel allowance, one way in connection with 
medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; 
prorated miles actually travelled." 
 
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 includes a 
laboratory report, with no documentation of travel, and therefore this procedure code and units billed 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 a travel allowance provided to the enrollee on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 2, 
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 this service is not appropriate for this place of treatment. 
 
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 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
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 the provider reported Current 
Procedural Terminology (CPT) 85060: Blood smear, peripheral, interpretation by physician with written report 
with no modifier appended, and place of service 22 On-campus outpatient hospital. In this case, this procedure 
was billed incorrectly, as an appropriate modifier would be appended. Therefore, this procedure code and place of service 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 laboratory services provided to the enrollee on January 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies provided to the enrollee on August 10, 
2021. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not paid separately. 
 
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 A0422 is "Ambulance (als or bls) oxygen and oxygen 
supplies, life sustaining situation."  
We find that procedure code A0422 is not supported in the medical record. Specifically, the supplies used 
during ambulance transport are included in the base payment for the ambulance services. They cannot be paid 
separately. Based on this information, we decided that Medicare rules for coverage of the supplies have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance supplies provided to the 
enrollee on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 30, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you were unaware that prior authorization 
was needed at the time of service, and it was medically necessary to treat the enrollee. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 30, 2021, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says the 
request is for services by a non-contracted provider for this date of service, and there is no referral letter from 
an in-network physician. The Plan also says that the services were not medically necessary, and there are in-
network providers available. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
November 10, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for urinary catheters billed with code A4351 for date of service September 
15, 2021. 
 
You asked the Plan to pay for the urinary catheters. You say that you have provided records to support payment 
for this code. The Plan denied your request. The Plan says that this code has a status indicator of "P" on the 
Medicare Physician Fee Schedule Database (MPFSDB) Physician Relative Value File; and is always bundled 
into payment for other services. 
 
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's sole denial rationale is that the code billed has a non-
payable status indicator on the MPFSDB Physician Relative Value File.  However, this argument is not 
applicable to this case.  This item was not billed by a physician or practitioner.  Rather, this item was provided 
and billed by a vendor that gets paid under the Durable Medical Equipment, Prosthetics/Orthotics and Supplies 
(DMEPOS) fee schedule.  This code is a payable code under this fee schedule.  The Plan has failed to address 
the fact that this is a payable code under the appropriate fee schedule.  The Plan has failed to even address 
coverage of this item at all under the DMEPOS fee schedule.  Finally, the Plan has failed to explain why it 
applied the physician fee schedule rules to this claim when the provider of service is clearly a DMEPOS 
vendor. Therefore, we decided that the Plan has to pay for urinary catheters billed with code A4351 for date of 
service September 15, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 7, 2021, 
to August 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that the diagnosis is supported by the physician's 
documentation. The Plan denied your request. The Plan says the diagnosis code for sepsis is not supported by 
the hospital record. 
 
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 A41.9, defined as sepsis, unspecified organism. 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 provided. Our physician 
reviewer found that the enrollee was admitted for the ongoing evaluation and management of small bowel 
obstruction. Initial therapy consisted of nasogastric decompression, intravenous fluids and empiric intravenous 
antibiotics. The enrollee experienced an unremarkable post-operative course. Upon review, despite presentation 
with small bowel obstruction and reported urinary tract infection, and elements of the Systemic Inflammatory 
Response syndrome, the hospital record does not support reporting a diagnosis of Sepsis for this hospital 
admission.  
 
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 August 7, 2021, to August 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that standard/usual work-up of hyponatremia has been completed. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there was a negative 
chest x-ray in 2020, and there has been none since. She has hyponatremia but the records show a referral to a 
nephrologist and urologist for medication management as possible cause of her low sodium. The medical 
necessity of CT of the chest at this point has not been established in the records provided. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management services 
provided to the enrollee on December 31, 2021. 
 
You asked the Plan to pay for the services. You say that the services were urgent and of medical necessity. The 
Plan denied your request. The Plan says since a qualifying initial or subsequent observation care service or 
another service resulting in an observation stay has not been reported, the discharge service is being denied. 
 
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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])." 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, observation discharge services cannot be reported without an accompanying initial and subsequent observation codes. 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 observation care discharge day management services provided to 
the enrollee on December 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and accessories. 
 
You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your 
request. The Plan says that no records were received to document the medical necessity of the request. 
 
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. Specifically, medical records were not provided for review in this 
case. The record shows that the Plan made multiple attempts to secure medical records, without success. 
Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this 
information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and 
accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate genetic testing (0005U). 
 
You asked the Plan to pre-approve prostate genetic testing. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says genetic testing is not 
reasonable and 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 prostate genetic testing. Our reviewer 
says that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
Our physician reviewer found the ExoDx Prostate test is a simple, non-DRE, urine-based, liquid biomarker test 
indicated for men aged 50 years and older with PSA levels between 2 and 10 ng/mL who are considering an 
initial biopsy or for men who received prior negative biopsy results and are considering a repeat biopsy. The 
records indicate that the enrollee already has been diagnosed and treated for prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve prostate genetic testing (0005U).