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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
June 27, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date of service June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta injections. 
 
You asked the Plan to pre-approve Zilretta. You say that this injection is medically necessary. The Plan denied 
your request. The Plan says this drug is not approved for the enrollee's condition. 
 
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 Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found Zilretta is an extended-release synthetic 
corticosteroid indicated as an intra-articular injection for the management of osteoarthritis-related pain of the 
knee. Zilretta has not been evaluated for the treatment of osteoarthritis-related shoulder pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require skilled nursing services, including administration of 
intravenous medication, bowel or bladder training, wound care, or tube feeding. The enrollee does not have the 
degree of medical complexity to necessitate care in skilled nursing facility setting. The enrollee also does not 
require the level of intensity of skilled therapy services provided in the skilled nursing facility setting. The 
enrollee has not had a significant decline in function and primarily requires oversight for safety, but this does 
not require skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac injection. You say that the first two epidural shots helped in the 
beginning. You also say that you can barely walk, stand, sit or lay down, and are in a lot of pain because the 
weather is getting colder. The Plan denied your request. The Plan says the documentation provided shows you 
had a previous joint injection with only 45% pain relief, and the pain returned in less than 3 months' time. The 
Plan also says due to inadequate pain relief and return of pain, you do not meet the guidelines for a repeat joint 
injection. 
 
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 sacroiliac injection. Our reviewer says 
that the requested sacroiliac injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 75% pain relief for at least 3 months was not achieved. 
 
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 sacroiliac injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac injection (27096).
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 August 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory 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 August 
1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Enhanced Steering Performance (ESP) enhanced 
driving feature. 
 
You asked the Plan to pre-approve an Enhanced Steering Performance (ESP) enhanced driving feature. You 
say that the requested Enhanced Steering Performance (ESP) enhanced driving feature is medically necessary. 
The Plan denied your request. The Plan says the requested Enhanced Steering Performance (ESP) enhanced 
driving feature 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 Enhanced Steering Performance 
(ESP) enhanced driving feature. Our reviewer says that the requested Enhanced Steering Performance (ESP) 
enhanced driving feature is not medically necessary. Our physician reviewer found the enrollee is tetraplegic. 
The group IV power wheelchair that has already been approved has features to enhance stability, and the ESP 
is 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 an Enhanced Steering Performance (ESP) enhanced driving feature have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an Enhanced Steering Performance 
(ESP) enhanced driving feature.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on August 22, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the services provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device 
(E0936). 
 
You asked the Plan to pre-approve a CPM exercise device. You say that you had knee surgery on November 7, 
2022, for rotator cuff tear. The Plan denied your request. The Plan says you had a left shoulder arthroscopy on 
November 7, 2022. There is no prescription for the requested device, and you did not have a knee replacement. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion (CPM) exercise device (E0936).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral augmentation and kyphoplasty of the L4 
vertebra. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding any compression fractures on the formal MRI report 
or the lumbar x-rays that were noted. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the enrollee does not meet the 
criteria for this request. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebral augmentation and kyphoplasty of the L4 vertebra.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that The enrollee will benefit from acute rehabilitation to 
optimize the level of function to return home and requires interdisciplinary therapy care. The Plan denied your 
request. The Plan says The IRF services being requested do not meet the requirements for approval. The 
records do not show that you need an intensive team for your care. The services you needed may be provided 
safely in other settings, for example, a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 is medically stable and does not need a rehabilitation physicians close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. The enrollee has no current medical complexity or rehab nursing needs. While 
the enrollee will benefit from physical therapy (PT) and occupational therapy (OT), these needs may be safely 
met in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair with a seat lift (E1399). 
 
You asked the Plan to pre-approve a recliner chair with a seat lift. You say that disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the requested item is not covered by 
Medicare or the plan. The recliner is only covered for an enrollee who is receiving dialysis. The recliner is 
considered furniture and does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair with a seat lift (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
19, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. 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 September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022, billed with 
codes 87798 and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 20, 2022, billed with codes 87798 and 87801.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (J1306) and the administration (96372). 
 
You asked the Plan to pre-approve Leqvio and the administration. You say that the enrollee is statin intolerant 
and needs to be approved for Leqvio to assist in the prevention of further coronary calcifications. The Plan 
denied your request. The Plan says Leqvio is a non-preferred product, and the enrollee does not have any stated 
contraindications to the preferred products. The Plan also says the enrollee has not tried any of the preferred 
agents, and a rationale is not provided for use of the non-preferred product for safety or efficacy.  
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 Leqvio and the administration. Our 
reviewer says that the enrollee does not meet the criteria for coverage for Leqvio. Our physician reviewer 
found there is no indication that the enrollee has tried and failed the Plan's required drug, Praluent. Our 
reviewer also found that there is no indication that the Plan's required drug 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 Leqvio and the administration have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Leqvio (J1306) and the administration (96372).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service June 20, 
2022. 
 You asked the Plan to pay for procedure code 99309. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99309 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99309 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99309 billed for date of service June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from April 11, 2022, to April 
20, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient services. You say that the diagnosis is supported by the physician's 
documentation. The Plan denied your request. The Plan says that sufficient documentation was not found to 
validate the diagnosis. 
 
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. 
 
We looked at the file and the rules. The Plan notes their decision to deny services was based on medical 
records. The case summary indicates medical records were received. The appeal also notes medical records 
were submitted. However, the Plan did not include medical records in the case file. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from April 
11, 2022, to April 20, 2022, at the Diagnosis Related Group (DRG) originally billed.  
 
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 Lisinopril. 
 
You asked the Plan to pre-approve Lisinopril. The Plan denied your request. The Plan says Lisinopril is a self-
administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lisinopril.  
 
  Benefits for Lisinopril 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 pre-approve laboratory testing provided on April 18, 2022. 
 
You asked the Plan to pre-approve lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says laboratory testing related to treatment of end-stage renal disease is bundled 
into payment for dialysis service and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for 
the treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) 
and are not paid separately.  
 
We looked at the file and Medicare rules. This lab testing is included in the ESRD PPS payment and is not paid 
separately. Based on this information, we decided that Medicare rules for coverage of lab tests have not been 
met. Therefore, we decided that the Plan does not have to pre-approve laboratory testing provided on April 18, 
2022.
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 July 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 July 14, 
2022.