Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 3, 2022, to July 
2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 3, 2022. The NOA was not received by the Plan until June 8, 2021. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
June 3, 2022, to July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation treatment delivery 
(IMRT), includes guidance and tracking (77386x25), intensity modulated treatment delivery, single or multiple 
fields/arcs, via narrow spatially and temporally modulated beams (G6015x25), a special treatment procedure 
(77470), a computed tomography guidance for placement of radiation therapy fields (77014x25) and 
stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy (G6002x25). 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says the plan benefits say Medicare does not cover unproven 
and not medically necessary procedures. There is not enough evidence that this type of radiation therapy is 
needed or effective for the enrollee's colon cancer. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found There are no consensus guidelines or literature to support the use of radiotherapy for 
this indication and the case file does not provide any evidence-based rationale for radiotherapy. The literature 
generally does not suggest a benefit for adjuvant radiotherapy, with perhaps a benefit in well-selected patients 
with T4b disease, though with limited data supporting adjuvant radiation, and with the case records not 
suggesting that this patient had T4b disease (with extension into nearby organs). 
 Furthermore, even if one were to accept the treatment  45 Gy in 25 fractions to the abdomen - as a standard of 
option, there is no dosiemetric rationale to deliver the treatment with IMRT vs. 3D conformal radiotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intensity modulated radiation treatment delivery (IMRT), includes guidance and 
tracking (77386x25), intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially 
and temporally modulated beams (G6015x25), a special treatment procedure (77470), a computed tomography 
guidance for placement of radiation therapy fields (77014x25) and stereoscopic x-ray guidance for localization 
of target volume for the delivery of radiation therapy (G6002x25).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intraperitoneal parenteral nutrition. 
 
You asked the Plan to pre-approve intraperitoneal parenteral nutrition. You say that you disagree with the 
denial. The Plan denied your request. The Plan says that based on the additional information available, the 
request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve intraperitoneal parenteral nutrition. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has end stage renal disease on peritoneal dialysis who has protein 
calorie malnutrition not due to malabsorption. Percutaneous gastrostomy tube is not indicated due to peritoneal 
dialysis. Malnutrition is associated with poorer mortality. Medicare has guidelines for nutritional goals in 
ESRD patients. The enrollee is unable to take adequate nutrition with diet and loses nutrients with the dialysis 
process. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraperitoneal parenteral nutrition have been met. Therefore, we decided that 
the Plan has to pre-approve intraperitoneal parenteral nutrition.  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee has a need for complex medical 
treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent 
intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound 
care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The requested treatments are not medically 
necessary at the LTACH level of care. The enrollee has improved medically and can receive further care at the 
current acute care hospital or a lower level of care when deemed appropriate. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81235, 81162, 81206, 
81301) provided on March 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered 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. 
 
This service was not supported by the medical records and procedure codes billed on this claim; therefore, it is 
not allowed.  As stated in The Centers for Medicare & Medicaid Services (CMS); National Correct Coding 
Initiative Coding Policy Manual for Medicare Services; chapter X states that "If a laboratory procedure 
produces multiple reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. If 
there is no HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or 
unlisted procedure code with a single unit of service. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (CPT code(s): 81235, 81162, 81206, 81301) provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) (L1971) and the heel stabilizer 
(L3170) provided on May 5, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items provided were not medically necessary for 
the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses (AFO) described by code L1971 
are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who require 
stabilization for medical reasons, and have the potential to benefit functionally. 
 
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 these items. Our reviewer says that the items 
provided were not medically necessary according to Medicare rules.  Our physician reviewer found that according to Medicare, an ankle-foot orthosis (AFO) can be covered if the 
beneficiary requires the AFO due to weakness or deformity of the foot and ankle. It can be approved for those 
who require stabilization for medical reasons and have the potential to benefit functionally. In this case, the 
documentation doesnt support that the enrollee had a joint that was unstable or that there was joint laxity in her 
ankle or foot. There is no indication that an AFO was required for stabilization for medical reasons or that there 
was a potential to benefit the enrollee functionally. The AFO orthosis and heel stabilizer provided were not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pay for the ankle-foot orthosis (AFO) (L1971) and the heel stabilizer (L3170) provided on May 5, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0428) provided on December 
23, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes A0425, A0428 is not supported in the medical record. Specifically, the enrollee was an 
inpatient December 
09, 2021, through December 24, 2021. Transportation services while an enrollee is an inpatient are not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance 
services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services 
(A0425, A0428) provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided 
to the enrollee on July 8, 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 records do not support the services 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 these services are not supported because there is no separate anesthesia record submitted for review. 
 
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 moderate sedation services (procedure code 99152) provided to the enrollee on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on May 27, 
2022. 
 
You asked the Plan to pay for the CxBladder Detect testing. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CxBladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on May 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
February 7, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that the claim was billed correctly. 
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. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service February 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 7, 2022 to 
February 5, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the "from" date on the NOA is January 7, 2022. The admit date on the claim does not match. 
Therefore, we decided that the Plan does not have to pay for home health services provided on January 7, 2022 
to February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 1, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 14, 2021, to December 24, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 DRG 853. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned principal 
diagnosis code with DRG. The replacement of DRG is upheld as it is supported by the medical documentation. 
The documentation does not indicate that the diagnostic work-up and treatment ordered by the treating medical 
providers supported a diagnosis code A41.50 (gram-negative sepsis unspecified). 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 14, 2021, to December 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management testing (0117U) provided on July 25, 
2022. 
 
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Per the Centers for Medicare and 
Medicaid Services Article A58801 it is not appropriate to bill Medicare for services that are not covered (as 
described by the entire LCD) as if they are covered. Consistent with the LCD, the following procedure code, 
0117U, is non-covered for pharmocogenomic testing. Therefore, we decided that the Plan does not have to pay 
for the pain management testing (0117U) provided on July 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 30, 2022, 
through May 29, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 admission date on the denied claim does not have the correct admission date of January 30, 2022. We find 
the Medicare rule for payment of the April 30, 2022, through May 29, 2022, claim has not been met. Based on 
this information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from April 30, 
2022, through May 29, 2022.