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

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that Botox is the only medication to treat the diagnosis. The 
Plan denied your request. The Plan says the clinical effectiveness in the setting of diabetic gastroparesis has not 
been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our physician reviewer found 
that the record indicates that the enrollee has a diagnosis of diabetic gastroparesis. The FDA has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression wraps and stockings identified with codes 
A6545 and A6549 that were issued on January 11, 2022. 
 
You asked the Plan to pay for the compression wraps and stockings. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this equipment correctly 
denied for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that compression wraps described by code A6545 are 
covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression 
bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying 
wound. The rules say that compression stockings described by code A6549 are noncovered because they do not 
meet the statutory definition of a surgical dressing. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. 
 
In addition, A6549 is noncovered because they do not meet the statutory definition of a surgical dressing.  
Therefore, we decided that the Plan does not have to pay for the compression wraps and stockings identified 
with codes A6545 and A6549 that were issued on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on December 1, 2021. 
 
You asked the Plan to pay for a shower chair. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on December 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 30, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 
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 0037U is targeted genomic sequency analysis, solid 
organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number 
amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the next generation 
sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for this gene is 
not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include 
the FANCC gene are statutorily excluded service. Based on this information, we decided that Medicare rules 
for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to 
pay for the FoundationOne CDx (F1CDx) test (0037U) provided January 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. This means that the profession component of these codes must be 
billed with modifier -26 for payment to be considered. The services in this case were not billed with modifier -
26. 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 lab services provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve an endosteal implant. You say that you would like authorization for this. 
The Plan denied your request. The Plan says the requested services are not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant (D6010) provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the medical services coded 93571, 93454, and 99232. We decided that 
the Plan does not have to pay for the moderate sedation services (99153).  
 You asked the Plan to pay for the catheter placement (93454), ultrasound evaluation of heart blood vessel and 
hospital services (99232). You say that you would like this claim reprocessed based on the medical records. 
The Plan says that the services have not been billed as required by Medicare coding regulations. 
 
We decided that the Plan has to pay for the medical services coded 93571, 93454, and 99232.  
 
The Plan follows 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, there is no reason presented as to why these services have been 
denied. Instead, the Plan indicates that they have been reopened as an OD reopen clerical error. The Plan has 
not made any effort to indicate the results of this reopening.  Therefore, we decided that the Plan has to pay for 
the medical services coded 93571, 93454, and 99232.  
 
We also decided that the Plan does not have to pay for the moderate sedation services (99153). 
 
The Plan follows Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a 
PC/TC indicator of 3 and no separate PC payment. These services were performed in the inpatient setting and 
no separate payment will be made beyond what was paid to the facility for the technical services. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services (99153). 
 
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 Hyalgan injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had 3 months of conservative therapy. 
 
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 the requested services. Our physician 
reviewer found that the record indicates the enrollee has a diagnosis of knee pain attributed to osteoarthritis.  
The record does not provide x-ray determination of the diagnosis, nor does it indicate the failure of a trial of 
conservative nonpharmacologic therapy. The FDA has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyalgan injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from April 5, 2021, through April 
13, 2021, at DRG 518. 
 
You asked the Plan to pay for inpatient services at DRG 518. The Plan denied your request. The Plan says 
diagnosis code M48.02 did not qualify for reporting as the principal diagnosis. 
 
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 with principal diagnosis code M48.02, defined as spinal stenosis, 
cervical region. 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 inpatient services at DRG 
518. Our reviewer says that the documentation does not support principal diagnosis of M48.02. Our physician 
reviewer found the documentation supports an admission for cerebral infarction due to embolism of right 
middle cerebral artery.  
 
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 services provided from April 5, 2021, through April 13, 2021, at DRG 518.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 7, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the physician provided medically necessary services 
and the services rendered meet professionally recognized standards of healthcare. You say that the claim 
should be processed for payment at the maximum amount allowed. The Plan denied your request. The Plan 
says the provider must attempt to consult the attending or primary care physician about the services furnished. 
 
  The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve an MRI. You say that you are appealing the denied service. The Plan denied 
your request. The Plan says the MRI request is not medically necessary under Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a magnetic resonance imaging (MRI). 
have been met. The appealing provider did not submit medical documentation to determine if the Medicare 
criteria was met for the MRI. Therefore, we decided that the Plan does not have to pre-approve a magnetic 
resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for J. Moreno Garcia, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. This means that the profession component of these codes must be 
billed with modifier -26 for payment to be considered. The services in this case were not billed with modifier -
26. 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 lab services provided on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 24, 
2021, to December 29, 2021. 
 
You asked the Plan to pay for critical care. You say that these services were billed appropriately and are 
supported in the record. The Plan denied your request. The Plan says these services are not supported in the 
medical record as billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing 
these services is not noted in the medical record. Based on this information, we decided that Medicare rules for 
coverage of critical care have not been met.  
 
 Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided on 
December 24, 2021, to December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. This means that the profession component of these codes must be 
billed with modifier -26 for payment to be considered. The services in this case were not billed with modifier -
26. 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 lab services provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sulfacetamide Sodium. 
 
You asked the Plan to pre-approve Sulfacetamide Sodium. The Plan denied your request. The Plan says this 
drug is not covered for the enrollee's condition by 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 Sulfacetamide Sodium.  
 
 
 Benefits for Sulfacetamide Sodium 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 1, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records do not include an order for 22 or more drug class(es), including metabolite(s). Based on this 
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 1, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on September 23, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that this testing was not requested by 
the ordering physician. 
 
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. In this case, the Plan has denied payment stating that they confirmed with the 
ordering providers office that the testing in question was not ordered. However, the Plan has not provided 
evidence that they spoke with someone at the providers office who confirmed that the testing was not ordered. 
Despite the Plans insistence that testing was not ordered, a test requisition form signed by the ordering 
provider appears in the record with no indication that this was not valid. Therefore, we decided that the Plan 
has to pay for the genetic testing services provided on September 23, 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.