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

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 
26, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 8. This code was billed with place of service 22 (outpatient hospital). This 
code is not payable with the billed place of service. Based on this information, we decided that Medicare rules 
for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not have 
to pay for the blood smear services coded 85060 provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient hospital care is not medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the active problem list does not indicate any cardiopulmonary conditions other than 
essential hypertension and peripheral vascular disease. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interpretation and report for a rhythm electrocardiogram 
(93042) billed for date of service March 21, 2022. 
 
You asked the Plan to pay for interpretation and report for a rhythm electrocardiogram. You say that the 
services at issue have been billed correctly for payment. The Plan denied your request. The Plan says the code 
at issue is included in another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 interpretation and report for a rhythm electrocardiogram. Our 
reviewer says that the billed code does not meet criteria for payment. Our reviewer found that in this case, 
electrocardiogram services would be included in critical-care services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interpretation and report for a rhythm electrocardiogram have not been met. 
Therefore, we decided that the Plan does not have to pay for interpretation and report for a rhythm 
electrocardiogram (93042) billed for date of service March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control for power wheelchair. 
 
You asked the Plan to pre-approve an attendant control. The Plan denied your request. The Plan says this is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. The requested attendant control is not covered in this case, as the 
intended wheelchair already has a beneficiary-operated drive control system. Based on this information, we 
decided that Medicare rules for coverage of an attendant control have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attendant control for power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron HCL. 
 
You asked the Plan to pre-approve Palonosetron HCL. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Palonosetron HCL. Our reviewer says 
that the documentation does not support that the requested drug is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of uterine leiomyosarcoma and is receiving 
chemotherapy with Gemcitabine and Docetaxel, considered a low emetogenic potential regimen. The Food and 
Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron HCL have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Palonosetron HCL.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 36556. The Plan denied your request. The Plan says payment for 
this code is bundled. 
 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 36556 
is a column II code to column I code 99292. 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 36556 billed for date of service June 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that Entyvio is medically necessary. The Plan denied your 
request. The Plan says a trial of Stelara is required before Entyvio can be considered. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drug or any reason it would be unsafe or ineffective 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
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 LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute-care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
 
  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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump for insulin. 
 
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 Medicare guidelines require C-Peptide or antibody screen test results in order to cover this pump. 
These results are not provided. 
 
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 an external ambulatory infusion pump for insulin.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services (S9122) and ambulance mileage 
(A0888) provided January 13, 2022, to April 28, 2022. 
 
You asked the Plan to pay for home health aide services and ambulance mileage. You say that this should be 
covered. The Plan denied your request. The Plan says these services were not provided by a Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health aide services (S9122) and 
ambulance mileage (A0888) provided January 13, 2022, to April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve a VIA Disc allograft intervertebral disc augmentation procedure. 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. 
 
The Plan follows Medicare rules. Medicare rules say that effective for services performed on or after 
September 29, 2008, the Centers for Medicare and Medicaid Services has determined that TIPs are not 
reasonable and necessary for the treatment of low back pain. 
 
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 VIA Disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found Via disc allograft is experimental in spine surgery. 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 a VIA Disc allograft intervertebral disc augmentation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc 
augmentation procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested services have been correctly denied due to medical 
necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found enrollee has normal range of motion. She has some reduced strength 
unrelated to her spine. Strength training is repetitive exercise and does not require continued input from a 
skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88381) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 88341, 88342, 88360, & 88381 are not supported in the medical record. Specifically, 
the codes billed have a professional component / technical component of 1. The claim has a place of service of 
22. The codes were not billed with the required 26 modifier. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88381) 
provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health medical services performed or supervised 
by licensed nurses. 
 
You asked the Plan to pre-approve home health medical services performed or supervised by licensed nurses. 
You say that in home care is needed to assist your family because there is no one available to assist you daily. 
You also say that you are home bound and need assistance. The Plan denied your request. The Plan says you do 
not meet the required criteria for coverage. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health medical services 
performed or supervised by licensed nurses. Our reviewer says that home health medical services performed or 
supervised by licensed nurses are not reasonable or necessary. Our physician reviewer found you do not have 
documented skilled nursing needs. Our reviewer found that you do not have documented skilled therapy needs. 
Our physician reviewer also found that the requested services are custodial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health medical services performed or supervised by licensed nurses have 
not been met. Therefore, we decided that the Plan does not have to pre-approve home health medical services 
performed or supervised by licensed nurses.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88360, 88381) provided January 18, 2022. 
 
You asked the Plan to pay for the lab 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88360, & 88381 are not supported in the medical record. Specifically, the codes billed 
have a professional component / technical component of 1 and were billed in a facility setting. The required 26 
modifier was not billed. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88360, 
88381) provided January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve a Synvisc injection. You say that you would like this to be reconsidered to 
allow the enrollee to undergo the 3-injection series and get back to living at a higher level with reduced pain. 
The Plan denied your request. The Plan says in order to continue receiving this medication, the documentation 
must show that the enrollee has had significant improvement in pain and functional capacity from the prior 
series of injections. The Plan also says that the records state the provider is unsure if it has been helpful. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 a Synvisc injection. Our reviewer says 
that a Synvisc injection is not reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of osteoarthritis of the knee, and they have previously 
received the requested treatment approximately six months ago with minimal benefit. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer 
found that the record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service at this time. Our physician reviewer also found that the elements of the 
coverage criteria are not satisfied, and 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 a Synvisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Synvisc injection.