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

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) provided December 14, 2021. 
 
 
You asked the Plan to pay for the laboratory services. You say that this test was ordered by the treating 
physician because the test results were needed to help determine the course of treatment for this enrollee The 
Plan denied your request. The Plan says Genetic testing procedures submitted with code 81455 are unlikely to 
impact therapeutic decision-making in the clinical management of the patient and will be denied automatically 
as 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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found FoundationOne Heme was sent for myeloproliferative neoplasm but the diagnosis 
code provided is for cervical cancer (stage IV). There are no medical notes provided for rationale for testing 
with next generation sequencing. The service was not reasonable or 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, 
DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) provided December 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that this is a Food and Drug Administration (FDA) 
approved treatment for the enrollee's condition. The Plan denied your request. The Plan says use of the 
requested drug in this instance is not supported in the compendia or in peer-reviewed medical literature. 
 
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 Enhertu. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of 
extramammary Paget's disease of the scrotum. The use of Enhertu is not FDA-approved for the enrollee's 
medical condition. There is insufficient support in the major drug compendia or clinical research that appears in 
a CMS-approved medial journal for the use of Enhertu as first-line treatment of extramammary Paget's disease 
of the scrotum. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
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 LTACH is medically necessary. The 
Plan denied your request. The Plan says authorization denied because the LTACH is not medically necessary, 
and the enrollee is receiving appropriate inpatient acute care. 
 
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 short-term acute care hospital can provide for all the enrollee's present inpatient 
care needs and the enrollee is receiving an appropriate level of care in the present 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) provided on March 15, 2022 to April 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP device. You say that you were in Florida for the winter. With you 
being in Florida you were unable to see your doctor. You were also never shown how to properly use the CPAP 
machine and have it set up to your phone. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 the continuous positive airway pressure (CPAP) 
device (E0601) provided on March 15, 2022 to April 14, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 
81442, 81161 and 81479 provided October 26, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that lab does not require active medica/state 
license and your lab is operating within Texas. Please reconsider the denial for this enrollee. The Plan denied 
your request. The Plan says the provider was not certified/eligible to be paid for this procedure/service on this 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services coded as 
81286, 81413, 81414, 81442, 81161 and 81479 provided October 26, 2021. have been met. The Plan made 
multiple attempts to obtain specific records was requested from the provider without success. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 81442, 
81161 and 81479 provided October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left supraorbital, supratrochlear, and infraorbital nerve 
pulsed radiofrequency (RFA) procedure under ultrasound provided to the enrollee on February 24, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of pulsed radiofrequency ablation in the setting of 
supraorbital, supratrochlear, and infraorbital neuralgia have not been demonstrated in the peer-reviewed 
literature. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested procedure is not accepted by Medicare. It is considered to be experimental and 
investigational. The approach of radiofrequency ablation of the terminal branches is not standard therapy for 
facial neuralgias. Additionally, correct coding requires services to be reported with the most specific code available that appropriately describes the service. CPT code 64400 is appropriate for a trigeminal nerve block. 
The correct code for a radiofrequency ablation procedure to the trigeminal nerve is 64600. 
 
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 pay for the left supraorbital, supratrochlear, and infraorbital nerve pulsed radiofrequency (RFA) 
procedure under ultrasound provided to the enrollee on February 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 24, 2022, to April 22, 2022. 
 
You asked the Plan to pay for SNF care. You say that this should be paid for. The Plan denied your request. 
The Plan says the Medicare criteria for continued SNF level of care is not met. 
 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 pay for 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 no longer qualified for SNF coverage. There were no documented 
skilled nursing or skilled therapy needs. The enrollee was constantly ambulating more than 100 feet and 
tending to activities of daily living with minimal supervision. Daily skilled services were not required to 
establish a maintenance program, or to prevent deterioration of the enrollee's condition. The enrollee's care 
needs were custodial and could have been provided at a lower level of care, such as home, assisted living, or 
long-term care. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from March 24, 2022, to April 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided to the enrollee on May 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this was billed correctly and is not bundled. The Plan 
denied your request. The Plan says payment may not be made for services included in the anesthesia care 
package when furnished by the same provider or the same provider specialty in a group practice. 
 
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 99231 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit." 
 
According to the coding guidelines, it would not be appropriate to bill this hospital care outside of the payment 
for the anesthesia services. 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 subsequent hospital 
care provided to the enrollee on May 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided on February 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an electrocardiogram. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan 
also says that the services were not referred by a network provider or rendered in an in-network facility. The 
Plan also says that they have determined that these services were not 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 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 an electrocardiogram provided on February 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Retacrit. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendium, DrugDex, states that the requested drug is indicated in anemic patients with cancer not receiving 
chemotherapy and has resulted in improved hemoglobin. The elements of the coverage criteria are satisfied. 
The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve 
Retacrit.  
 
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: 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 the enrollee needs rehabilitation to get stronger so 
she can eventually go home. You says that the enrollee needs help standing, bathing, and feeding. The Plan 
denied your request. The Plan says based on Medicare guidelines; the skilled nursing facility services do not 
meet the requirements for approval. 
 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 is not able to make material gains within a predictable time frame. 
Her dementia likely inhibits her ability to respond to 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Corflex device (22867). 
 
You asked the Plan to pre-approve the Corflex device. You say that the enrollee needs this surgery done. She is 
in too much pain and cannot walk, lay down or stand on her own. The Plan denied your request. The Plan says 
The requested Coflex lumbar interspinous decompression device is unproven and not medically necessary due 
to insufficient evidence of efficacy. 
 
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 Corflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found interspinous devices are experimental. More research is needed to show safety and 
efficacy. 
 
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 Corflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Corflex device (22867).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injections (CPT code(s): 64493 and 64493). 
 
You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 the injections. Our physician reviewer 
found the Medicare LCD states that in order for this procedure to be covered there must be Absence of 
untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial 
cyst). Therefore, the request is deemed not medically reasonable or 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injections (CPT code(s): 64493 and 64493).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0245U) provided to the 
enrollee on March 9, 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 there are no modifiers that are allowed with this code pair. 
 
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 0245U 
is a column II code to column I code 0018U with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (procedure code 0245U) provided to the enrollee on 
March 9, 2022.
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 you need to go to a rehabilitation facility because 
you cannot walk and will be in danger if you go home by yourself. The Plan denied your request. The Plan says 
SNF care is not medically necessary and your needs can be met at a lower level of care such as nursing or 
therapy services provided at home or in a provider's office. 
 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 you do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care other than a skilled nursing facility. You do not have 
any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable 
without any acute exacerbations of chronic medical problems. Your physical function is at or near your 
baseline and you can receive services at a lower level of care 
 
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.