Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from August 19, 2021, through 
August 23, 2021, at DRG 166. 
 
You asked the Plan to pay for inpatient services at DRG 166. You say that the clinical documentation supports 
reporting J96.01, which supports DRG 166. You say that you disagree with the decision to change the DRG 
and the DRG should remain as originally reported. The Plan denied your request. The Plan says secondary 
diagnosis code J96.01 is not supported. 
 
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 with secondary diagnosis code J96.01, defined as acute respiratory 
failure, not elsewhere classified Type 2 [with hypercapnia]). 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 inpatient services at DRG 166. Our reviewer says that the documentation does not support 
secondary diagnosis code J96.01. Our physician reviewer found that there was no documentation of acute 
respiratory failure. Although the provider documented acute respiratory failure, reasonable support within the 
health record must be present for that diagnosis.  
 
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 services provided from August 19, 2021, through August 23, 2021, at DRG 166.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laser astigmatism correction (A9270) provided January 24, 
2022. 
 
You asked the Plan to pay for the laser astigmatism correction. You say that this service was medically 
necessary. The Plan denied your request. The Plan says an astigmatism correcting lens is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for laser astigmatism correction 
(A9270) provided January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthoisc or Supartz FX. 
 
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 Hyalgan. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that there has been trial and failure of Orthovisc or Supartz FX. The reviewer found that the 
documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Promethazine.  
 
Benefits for Promethazine 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2022 to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2022 to May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Zoledronic acid. The reviewer found that the 
documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have 
adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87653, 
87798, and 87801 billed for date of service September 22, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87653, 87798, and 87801. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87150 is bundled into payment for code 87500. Procedure code 87500 is not 
supported in the records provided. Payment for code 87481 is bundled into payment for codes 87150 and 
87801. Payment for code 87640 is bundled into payment for codes 87150, 87641, and 87801. Payment for code 
87641 is bundled into payment for codes 87150 and 87801. Payment for code 87653 is bundled into payment 
for codes 87150 and 87801. Payment for code 87798 is bundled into payment for codes 87150 and 87801. 
Payment for code 87801 is not supported in the records provided. 
 
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 87150 
is a column II code to column I code 87500. Code 87500 is not supported in the records provided. Code 87481 
is a column II code to column I codes 87150 and 87801. Code 87640 is a column I code to column II codes 
87150, 87641, and 87801. Code 87641 is a column I code to column II codes 87150 and 87801. Code 87653 is 
a column I code to column II codes 87150 and 87801. Code 87798 is a column I code to column II codes 87150 
and 87801. Payment for code 87801 is not supported in the records provided. 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 codes 87150, 87481, 
87500, 87640, 87641, 87653, 87798, and 87801 billed for date of service September 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 15, 
2022. 
 
You asked the Plan to pay for F1CDx testing. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says that there is a Local Coverage Determination 
(LCD) that indicates that any panel that tests for the FANCC gene is noncovered. They argue that since this 
panel includes that specific gene, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on February 15, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Ellipta (J3535). 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that the enrollee needs this drug. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Trelegy Ellipta (J3535).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex scan of extracranial arteries; complete bilateral study 
(93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that the requested scan is 
medically necessary. The Plan denied your request. The Plan says that the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a duplex scan of extracranial arteries. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee complains of loss of consciousness and continued feeling 
somewhat slow and off balance. She also has been complaining of left-sided neck pain. As the enrollee was not 
immediately seen following the symptoms, it is unclear if her symptoms represented a drop attack or a 
TIA/stroke. She has an additional risk factor, hypertension. Carotid duplex is medically necessary to assess for 
carotid stenosis, as well as assess for vertebral flow as the enrollees symptoms may be related to subclavian 
disease. The health plan acknowledges that carotid disease could cause sympathy. 
 
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 duplex scan of extracranial arteries have been met. Therefore, we decided that 
the Plan has to pre-approve a duplex scan of extracranial arteries; complete bilateral study (93880).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid, monaural, in the ear (V5050 LT, RT) purchased 
April 30, 2022 from an out of network provider 
 
You asked the Plan to pay for hearing aids. You say that you had the services done understanding that you did 
not need an authorization from your primary care physician.  You expect to be reimbursed the $1,395.00 that 
you paid with trusting that your medical Plan was going to reimburse you. The Plan denied your request. The 
Plan says enrollees must receive their hearing aid services from an in-network provider. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The record shows you 
received the hearing services from an out-of-network provider. Though the Plan offers a hearing benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aid, 
monaural, in the ear (V5050 LT, RT) purchased April 30, 2022 from an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on 
October 28, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the billing process was delayed due to the 
pandemic, being short staffed, and an overwhelming increase of patient flow. The Plan denied your request. 
The Plan says the claim was not received within 12-months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the nursing facility care was not filed until March 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on October 
28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested implantable loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder. Our physician 
reviewer found the enrollee has documented atrial fibrillation. There is no evidence that the implantable loop 
recorder (ILR) results would change the enrollees medical management. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric scale. 
 
You asked the Plan to pre-approve a bariatric scale. You say that this is medically necessary due to rapid 
weight increase. The Plan denied your request. The Plan says this is not covered per Medicare rules. 
 
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 bariatric scale.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on March 15, 
2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
(A9270) provided on March 15, 2022.  Benefits for this item 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this should be approved. The Plan denied your 
request. The Plan says that the enrollee has not tried at least one tyrosine kinase inhibitor (TKI), a targeted 
therapy identifies and attacks specific types of cancer cells while causing less damage to normal cells. 
 
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 Keytruda. Our reviewer says that the 
requested drug, Keytruda, is medically reasonable and necessary. Our physician reviewer found the Food and 
Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's specific clinical 
condition. The Medicare approved cancer drug compendium, DrugDex, states that the requested drug has an 
orphan drug designation for the noted indication. This is a positive citation within a Medicare approved 
compendium. Therefore, the reviewer found that the requested drug is medically reasonable and 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda (J9271).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90791) provided on March 
16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-
approved. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services 
(90791) provided on March 16, 2021 by an out-of-network (OON) provider.