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

 
We decided that the Plan does not have to pre-approve Genvisc 850 (J7320). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested medication does not meet step therapy criteria. 
 
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 the medication. Our physician reviewer 
found the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850 (J7320).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the proton beam radiation therapy (PBRT) (77525).  
You asked the Plan to pre-approve the radiation therapy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's records do not show that surrounding tissue cannot be 
protected enough with photon-based radiation therapy. 
 
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 radiation therapy. Our physician 
reviewer found PBRT is not medically necessary in this case. There is insufficient prospective, long-term 
clinical data available to determine whether or not proton beam radiation therapy for prostate cancer is 
superior, inferior, or equivalent to external beam radiation therapy, intensity-modulated radiation therapy 
(IMRT), or brachytherapy with regards to safety and efficacy. Recent data shows no significant differences in 
late (years one, two, and three) patient-reported toxicity outcomes between proton beam therapy and IMRT. 
The most recent American Urological Association (AUA) and National Comprehensive Cancer Network 
(NCCN) guidelines state that PBRT offers no clinical advantage over other forms of definitive treatment. 
According to NCCN and American Society for Radiation Oncology (ASTRO) guidelines, proton beam therapy 
may be offered to individuals enrolled in an Institutional Review Board (IRB) approved prospective clinical 
trial or multi-institutional registry that adheres to Medicare requirements for coverage with evidence 
development (CED). 
 
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 radiation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the proton beam radiation therapy (PBRT) (77525).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053 and 85025 billed for date of service 
May 9, 2022. 
 
You asked the Plan to pay for procedure code 80053 and 85025. You say that you are requesting an appeal for 
claims associated with the emergency room visit and admission as inpatient for dates of service May 9, 2022, 
to May 11, 2022. The Plan denied your request. The Plan says procedure code 80053 and 85025 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 80053 and 85025 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure codes 80053 and 85025 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure code 80053 and 85025 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 80053 and 85025 billed for date of service May 
9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
September 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says an individual provider 
cannot bill for OTP services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities.  
 
We looked at the file and Medicare rules. In this case, the billing provider is not eligible to bill for OTP 
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 the opioid treatment program (OTP) services 
provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that this dental work is 
medically necessary. The Plan denied your request. The Plan says the medical criteria for D4341 have not been 
met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing when the services are medically necessary and reasonable.  
 
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 periodontal scaling and root planing. 
Our physician reviewer found the documentation provided does not meet the criteria for coverage for 
periodontal scaling and root planing (D4341) in four quadrants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight pharmacogenomics testing (81479) provided May 
7, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this appeal should be approved and paid at the 
established rate of $901.82 for Genesight testing under CPT code 81479. The Plan denied your request. The 
Plan says the records do not support that this care is needed to treat the enrollee's condition and does not 
support the 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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, it was noted that the enrollee has a history of anxiety and depression. The enrollee 
was not currently being treated and there was no mention in the provider's note that the enrollee's symptoms 
were uncontrolled or refractory to prior treatment. There is no specific clinical rationale for the requested 
testing. The review has determined that the records provided did not support that the services met the medically 
necessary criteria for Medicare coverage. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for GeneSight pharmacogenomics testing (81479) provided May 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional SNF care days. 
 
You asked the Plan to approve additional SNF care days. You say that because you had COVID, you did not 
receive the physical therapy you needed, and you need more therapy to be discharged safely. The Plan denied 
your request. The Plan says you have exhausted your benefit for 100 days in a SNF. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 29, 2022, to March 
16, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to approve additional inpatient SNF care days.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that it is necessary to 
have transportation to this facility for follow-up care. The Plan denied your request. The Plan says the 
requested transportation exceeds the Plan's mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
We looked at your request, the records in the case file, and the rules. We verified that the requested 
transportation exceeds the Plan's mileage limit. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) services. 
 
You asked the Plan to pre-approve SSBCI services. You say that the medical records provided support the need 
for SSBCI care. The Plan denied your request. The Plan says there is no documentation supporting that the 
enrollee meets the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found that, although the enrollee has many 
chronic, stable conditions being managed appropriately by the treating physician, the enrollee does not have an 
active diagnosis for one or more qualifying comorbid and medically complex conditions. The enrollees 
conditions are not life-threatening or significantly limiting the overall health or function of the enrollee. The 
enrollee does not require intensive care management and is not at a high risk for hospitalization based on the 
provided documentation.   
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI services have not been met. Specifically, we have confirmed that you do 
not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan 
does not have to pre-approve special supplemental benefit for the chronically ill (SSBCI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve a complete lower denture. You say that you have pain and swelling in your 
gums when you eat without dentures. The Plan denied your request. The Plan says the requested service 
exceeds the frequency limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a complete 
lower denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete lower 
denture was previously covered on June 29, 2022. Based on this information, we decided that the Plan's 
frequency limit for coverage of a complete lower denture will be exceeded with the requested service. 
Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99223) provided on July 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that procedure code 
99223 is included in procedure code 99223 for the same day, same condition, and same specialty in the same 
group practice. 
 
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 argues that code 99223 is not payable because it was billed with code 
99223 on the same date, and by the same group practice. However, the records show that only one unit of code 
99223 was billed on the date of service in question. As such, the Plan has not provided documentation 
supporting its denial. Therefore, we decided that the Plan has to pay for the services (99223) provided on July 
31, 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: 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 enrollee requires daily physician 
visits, physical therapy and wound care management. The Plan denied your request. The Plan says the 
enrollee's records do not show that you need continued treatments and care that can only be given in a hospital 
setting. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 pre-approve a high frequency chest wall oscillation system 
(HFCWOS) (E0483). 
 
You asked the Plan to pre-approve a HFCWOS. You say that you feel the enrollee would benefit from the 
requested device. The Plan denied your request. The Plan says the enrollee does not have a qualifying condition 
and therefore the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation system (HFCWOS) (E0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from January 18, 2022, 
to January 20, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
physician diagnosed the enrollee and clearly documented the diagnoses. You say that denial should be 
overturned, and payment approved at the originally billed DRG. The Plan denied your request. The Plan says 
the records do not support diagnosis codes J12.82, J10.08 and E87.1. 
 
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 J12.82, J10.08 and E87.1, defined as pneumonia 
due to coronavirus disease, influenza due to other identified influenza virus with other specified pneumonia and 
hypo-osmolality and hyponatremia. 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 there is insufficient 
documentation to support diagnosis codes J12.82, J10.08 and E87.1. Our physician reviewer found the 
provided records did not clearly show evidence of a pneumonia based on physical findings, blood work, or 
imaging to justify the diagnoses. The enrollee also did not receive aggressive treatment for hyponatremia to 
show that this condition was treated in the hospital.  
 
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 from January 18, 2022, to January 20, 2022, at the DRG originally 
billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 14, 2022. 
 
You asked the Plan to pay for the genetic testing billed. 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 
July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 99292. The Plan denied your request. The Plan says payment for 
code 99292 is bundled into payment for code 36556.  
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 99292 
is a column II code to column I code 36556. 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 99292 billed for date of service March 7, 2022.