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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 13, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 13, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee may benefit from physical and 
occupational therapy but does not need the intensity of these therapies provided in the acute inpatient 
rehabilitation setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (KO), single upright, thigh, and calf, 
with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with 
or without varus/valgus adjustment, prefabricated, off-the-shelf (L1851). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the brace would benefit the enrollee greatly. 
The enrollee has chronic knee pain for many years and has tried conservative therapy in the form of Tylenol, 
physical therapy, biking/cycling, compression sleeves and massage therapy. The Plan denied your request. The 
Plan says the records show a diagnosis of arthritis in the knee. The enrollee has not had a recent injury or 
surgery to his knee and the notes do not show that his knee is unstable on exam. The enrollee does not meet the 
requirements for approval. 
 
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 knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided medical records do not document the enrollee has had a recent injury to or a surgical 
procedure on the knee. Records do not document knee instability by examination of the enrollee and objective 
description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test) as required by the LCD. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (KO), single upright, thigh, and calf, with adjustable flexion and extension 
joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, 
prefabricated, off-the-shelf (L1851).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 10, 2022. 
 
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 August 10, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam by a pathologist (88305) provided on June 
22, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 21, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the tissue exam by a 
pathologist (88305) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PluraPly AM. 
 
You asked the Plan to pre-approve PluraPly AM. You say that you fell two months ago. You say that you have 
been seeking wound care. You say that you are worried about losing your leg as your injury has not healed 
completely. You also say that you have poor circulation and stints which may be hampering your recovery. The 
Plan denied your request. The Plan says the requested treatment 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 PluraPly AM. Our reviewer says that 
the requested PluraPly AM is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that the wound is improving with current conservative 
treatments. Therefore, the reviewer found that the requested PluraPly AM application is not medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PluraPly AM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PluraPly AM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this is a covered outpatient procedure which 
should be paid. The Plan denied your request. The Plan says payment is not recognized for this service as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the standard wheelchair (K0001) and elevating leg rests (K0195), 
rendered on May 23, 2022. 
 
You asked the Plan to pay for the standard wheelchair and elevating leg rests. You say that the items should be 
covered. The Plan denied your request. The Plan says that the enrollee has exceeded the frequency set by 
Medicare per the capped rental items. 
 
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. The Plan did not submit documentation showing that the enrollee exercised a 
purchase option or that 15 months were paid for these items. Therefore, we decided that the Plan has to pay for 
the standard wheelchair (K0001) and elevating leg rests (K0195), rendered on May 23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often.  
 
 
 
 
 
  
If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with pemetrexed (J9305). 
 
You asked the Plan to pre-approve pemetrexed. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label 
and not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pemetrexed. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of pemetrexed is not FDA-approved for the enrollees diagnosis. The use is not supported by one 
of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pemetrexed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with pemetrexed (J9305).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail polymerase chain reaction (PCR) panel provided on 
July 6, 2022. 
 
You asked the Plan to pay for the nail PCR panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation shows that the enrollee's nails on feet were hypertrophic, 
discolored, with subungual debris characteristic of onychomycosis and was diagnosed with Tinea unguium. In 
this clinical setting which shows the exam was strongly suggestive of onychomycosis, empirical treatment with 
an antifungal treatment is recommended without the need for identifying the exact organism, and this is 
standard of care. If identification is warranted for more confusing case presentation, culture is standard of care, 
not PCR. Therefore, the services received were 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 pay for the nail PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 the nail PCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the nail polymerase chain reaction (PCR) panel provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001, 77401). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the enrollee has a biopsy 
proven squamous cell carcinoma on the left upper cutaneous lip. Due to mitigating factors such as tissue 
mobility, advanced age, tumor location, cosmesis, the enrollee is refusing surgery due to location, and size of 
the lesion. It has been determined that Image-Guided Superficial Radiation Therapy (IG -SRT} was medically 
necessary and the appropriate course of treatment. The Plan denied your request. The Plan says the request 
does not meet the Medicare or health plan coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image 
guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy 
of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow 
reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is FDA approved 
for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply 
that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations 
and/or IGRT for a technology for which need has not been established by published data or supported by 
consensus guidelines is not necessary. Billing for daily IGRT or daily simulations (also requested in this case) 
would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001, 77401).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (E0747). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you have submitted additional 
medical records from 9/23/2022, as well as published medical studies addressing the efficacy of the requested 
device.  The Plan denied your request. The Plan says the requested bone growth stimulator is non-coverable, in 
accordance with CMS criteria, because it is not reasonable or necessary. 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 osteogenesis stimulator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found based on the medical 
records provided, there is no documentation that the osteogenesis stimulator at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee. Provided medical records document 
"delayed healing" of the fractures but provided records do not document that fracture healing has ceased as 
required by the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National 
Coverage Determinations Manual, Section 150.2. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, other than spinal 
applications (E0747).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee has not had a significant decline from her baseline level of function and does require the intensity of therapies provided on acute 
inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documentation supports medical necessity. The 
Plan denied your request. The Plan says this service is not supported by the codes billed on the claim. 
 
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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This 
means that no TC billing is recognized because payment for the underlying clinical laboratory test is made to 
the hospital. No payment is recognized for CPT code 85060 furnished to hospital outpatients or non-hospital 
patients. Based on this information, we decided that Medicare rules for coverage of procedure code 85060 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 85060 billed for 
date of service July 13, 2022.