Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan, of the chest, diagnostic; 
without contrast material (71250). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the chest is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that a repeat CT scan of the chest is 
medically reasonable and necessary. This enrollee is being followed for interstitial lung disease, with findings 
consistent with pulmonary fibrosis. The chest CT scan will help determine whether there is progression of the 
fibrosis, and whether treatment is indicated. Progression can occur even when symptoms are stable. Delaying 
treatment can lead to irreversible loss of lung function.    
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan, of the chest, diagnostic; without contrast material (71250).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections (ESI) (64484, 64483). 
 
You asked the Plan to pre-approve the ESI's. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESI will be considered medically necessary when 
there is pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or 
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes 
zoster refractory to conservative management where a four (4) week wait is not required. 
 
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 ESI's. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found the documentation does not reveal failure to 
respond to four (4) weeks of noninvasive conservative care or acute herpes zoster refractory to conservative 
management where a four (4) week wait is not required. 
 
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 ESI's have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the epidural steroid injections (ESI) (64484, 64483).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 14, 2022, to 
February 12, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA received was incorrect. 
 
The Plan follows Medicare rules. The rules say that an NOAs must be submitted correctly for home health 
services claims to be paid. 
 
Review of the file shows that three NOAs were submitted with from and through dates as January 14, 2022. 
However, the claim for the 30-day period of care is submitted incorrectly with the admit date as November 15, 
2021. As the NOA submitted is incorrect, no payment can be made on this claim. Therefore, we decided that 
the Plan does not have to pay for the home health services provided January 14, 2022, to February 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on July 30, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $239.73, which is less than the $250 copayment for CT scan. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for CT scan provided on July 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug injections provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug injections. You say that the services were medically necessary, and 
authorization was received. The Plan denied your request. The Plan says a valid referral/authorization for the 
requested drugs was not obtained prior to services being rendered. The authorization indicated was not 
associated with the pharmacy department. 
 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 drug injections provided on July 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal orthosis provided on May 24, 2022. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered for the indications 
established in the applicable LCD. 
 
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 orthosis. Our reviewer says that the 
requested spinal orthosis is not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee had a medical condition that would necessitate the use of a 
rigid-corset-style brace that is typically prescribed for use after surgery. The prescription does not indicate that 
this item was coded correctly as it states the requested orthosis is "flexible". 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the spinal orthosis provided on May 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) (64625) of the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve an RFA of the SI joint. You say that the denial of this service is tortuously 
interfering with the enrollee's healthcare that has documentation and positive benefits from the procedures. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an RFA of the SI joint. Our physician 
reviewer found the documentation does not support that the SI joint RFA is medically reasonable or necessary 
for the enrollee. Our reviewer also found that the documentation does not support that the RFA is safe and 
effective 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 an RFA of the SI joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a radiofrequency ablation (RFA) (64625) of the sacroiliac (SI) joint.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 11, 
2022. 
 You asked the Plan to pay for procedure code 87634. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87632. 
 
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, we have confirmed that code 87634 
is a column II code to column I code 87632. 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 procedure code 87634 billed for date of service January 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services are covered by Medicare. 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 November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 2, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria (pegfilgrastim-apgf) (Q5122). 
 
You asked the Plan to pre-approve Nyvepria. You say that the enrollee has not tried the preferred drugs. You 
say that you have other patients on the requested drug. You also say that you are not able to stock multiple 
drugs at once. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred 
drugs, Neulasta (pegfilgrastim) or Fulphila (pegfilgrastim-jmdb) or Ziextenzo (pegfilgrastim-bme). 
 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 Nyvepria. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed any of the plan's preferred drugs. The reviewer also found that there is 
no indication that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred drugs. 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 Nyvepria have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nyvepria (pegfilgrastim-apgf) (Q5122).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214 and 95251 provided to the enrollee 
on April 29, 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 Original Medicare would be responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99214 and 95251 provided to the enrollee on 
April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 24, 2022, to May 
28, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like the denial to be 
overturned, and the payment for the inpatient hospital treatment rendered appropriately. The Plan denied your 
request. The Plan says that this stay is denied. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from May 24, 2022, to May 28, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43626 billed for date of service June 10, 
2022. You asked the Plan to pay for procedure code 43626. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 43626 is bundled into payment for code 43274. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 43626 is a column II code to column I code 43274. While code 
43626 was billed with modifier -59, the medical records provided do not show that this service is a distinct 
procedural service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 43626 billed for date of service June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20245) provided on May 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20245 is "Biopsy, bone, open; deep (eg, humeral shaft, 
ischium, femoral shaft)". 
 
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 20245 is 
not supported by the records provided. Our reviewer found that the medical record shows that the provided 
service was a bone biopsy for phalanx, which does not support code 20245. There is a more appropriate code 
for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (20245) provided on May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 3, 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 the provider verbally confirmed that you are aware that the services are not eligible for payment 
or reimbursement under Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for surgical 
services provided to the enrollee on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing provided on May 24, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne 
CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx testing provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthotic brace. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro myoelectric orthotic brace.