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

 
We decided that the Plan does not have to pre-approve Nplate. 
 
You asked the Plan to pre-approve Nplate. You say that use of Nplate could possibly make a difference in the 
enrollee's ability to resume treatment for multiple myeloma with the goal to transition to a bone marrow 
transplant, and hopefully remission. The Plan denied your request. The Plan says Nplate is not indicated for 
treatment of low platelets or to normalize platelets to prepare for chemotherapy treatments. 
 
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 Nplate. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found Nplate is not indicated for the treatment 
of thrombocytopenia due to myelodysplastic syndrome or any cause of thrombocytopenia other than immune 
thrombocytopenia (ITP). As the exact diagnosis in this case is not clearly ITP, then the requested use of Nplate 
is not FDA-approved for the enrollee's diagnosis. The use of Nplate for any cause of thrombocytopenia other 
than ITP is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. Nplate is not considered reasonable and necessary for this 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 Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nplate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S1015, S8301, A4253, A4556, A4557, 
A4649, and 99072, billed for date of service April 19, 2022. 
 
You asked the Plan to pay for procedure codes S1015, S8301, A4253, A4556, A4557, A4649, and 99072. You 
say that fafasfd The Plan denied your request. The Plan says the billed codes are 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 codes S1015 and S8301 have a status indicator of I on the Physician Fee Schedule. This 
means that procedure codes S1015 and S8301 are not valid for Medicare purposes. We also find that procedure 
codes A4253, A4556, A4557, and A4649, have a status indicator of P on the Physician Fee Schedule. This 
means that no payment cannot be made for these services. Finally, procedure code 99072 is assigned a status 
indicator of B on the Physician Fee Schedule. This means that procedure code 99072 is not separately payable. 
A Based on this information, we decided that Medicare rules for coverage of procedure codes S1015, S8301, 
A4253, A4556, A4557, A4649, and 99072 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes S1015, S8301, A4253, A4556, A4557, A4649, and 99072, billed for date of 
service April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82570 and 83986 billed for date of service 
March 30, 2022. 
 
You asked the Plan to pay for the services. You say that these services are supported in the medical record and 
should be paid. The Plan denied your request. The Plan says although these services were billed with a 
modifier for separate payment, the records do not support the use of this modifier in this case. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
medical documentation does not support the use of modifier -59. The denied services were neither separate nor 
distinct from procedure code 80307. 
 
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 procedure codes 82570 and 83986 billed for date of service March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 7, 
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 is no documentation to support genetic testing on the billed date of service. 
 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected. 
 
The date of service for this case should have been when the specimens were collected, not the date the services 
were rendered on March 7, 2022. 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 laboratory services 
provided to the enrollee on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a pneumatic 
appliance for the leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and appliance for the leg. You say that the device 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for approval of the requested device. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found provided records 
do not document (with adequate detail) trial and failure of at least four weeks of conservative therapy for the 
lymphedema as required by Local Coverage Determination (LCD): Pneumatic Compression Devices - L33829. 
As stated in the LCD: "At a minimum, re-assessments conducted for a trial must include detailed 
measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at 
the conclusion of the various trials and therapy, with bilateral comparisons where appropriate." Provided 
records do not provide this level of detail with regard to the prior treatment of the lymphedema. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a pneumatic appliance for the 
leg (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for January 13, 2022. 
 
You asked the Plan to pay for procedure code 84480. The Plan denied your request. The Plan says procedure 
code 84480 is bundled into code 84481. 
 
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 84480 
is a column II code to column I code 84481 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 procedure code 84480 billed for January 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that the non-preferred drug is needed because of 
the enrollee's neuropathy. The Plan denied your request. The Plan says there is no record showing that the 
enrollee has tried the preferred drug, that it hasn't worked, or that the enrollee has medical reasons that prevent 
them from using it. 
 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 Darzalex Faspro. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug 
Velcade before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plans required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81407, 
81406, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says if laboratory assays two or more genes in a patient in parallel, then those two or 
more genes will be considered part of the same panel. 
 
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 
February 21, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, 0033U, 81407, 81406, and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, S8301, A4556, A4557, 
A4649, & 99072 billed for date of service February 28, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015, S8301, A4556, A4557, A4649, & 99072. You 
say that the services were medically necessary. The Plan denied your request. The Plan says procedure codes 
A9279, S1015, S8301, A4556, A4557, A4649, & 99072 are 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 codes A9279, S1015, & S8301 have a status of I and are not eligible for payment. 
Codes A4556, A4557, & A4649 have a status indicator of P on the Physician Fee Schedule. Code 99072 has a 
status of B. This means that these codes are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes A9279, S1015, S8301, A4556, A4557, A4649, & 99072 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, S1015, 
S8301, A4556, A4557, A4649, & 99072 billed for date of service February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 provided on 
February 28, 2022. 
 
You asked the Plan to pay for procedure codes 51785, 95861, and 95870. You say that the medical records 
support the billing of codes 51785, 95861, and 95870. The Plan denied your request. The Plan says the medical 
records do not support the billing of codes 51785, 95861, and 95870. 
 
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 51785 is Needle electromyography studies (EMG) of 
anal or urethral sphincter, any technique. The definition of code 95861 is Needle electromyography; 2 
extremities with or without related paraspinal areas. The definition of code 95870 is Needle electromyography; 
limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic 
paraspinal, cranial nerve supplied muscles, or sphincters. 
 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 procedure codes 51785, 95861, and 95870. Our reviewer 
says that the medical records do not support the billing of codes 51785, 95861, and 95870. Our reviewer found 
procedure code 51785 was signified with the statement "Subdermal electrodes were placed in the anal sphincter 
to monitor electromyographic (EMG) responses during the procedure" This statement does not accurately 
describe the procedure being done that is required for proper documentation and therefore cannot be properly 
verified. Procedure code 95861 is not supported by the documentation as there is a more appropriate procedure 
code that described the procedure that was performed. Procedure code 95870 is not properly documented and 
cannot be verified within the operative report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 51785, 95861, and 95870 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 provided on February 
28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the rehabilitation and cannot get 
the desired services at a lower level of care. The Plan denied your request. The Plan says the criteria for IRF 
admission were not met and the enrollee's needs can be provided at a lower level of care like at a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee can 
receive further 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is alert, following 
commands, and actively tolerating weaning modes on the ventilator. You say that the enrollee will benefit from 
an LTACH level of care and is stable for discharge. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 appears to be more stable and improving and should only require short-
term additional acute care services, including weaning, that can safely be administered at the current facility. 
Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment at the 
current facility 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 billed for date of service June 23, 
2022. 
 You asked the Plan to pay for procedure code G0416. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0416 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0416 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0416 billed for date of service June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve a non-spinal electrical osteogenesis stimulator. You say that the device is 
medically necessary. The Plan denied your request. The Plan says you are currently 5 months post-surgery. The 
criteria is not met since a minimum of nine months has not elapsed since the surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a non-spinal electrical osteogenesis 
stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you presented with right foot pain. You underwent hallux 
valgus correction of the right great toe on 3/9/22. You report continued swelling and pain in the plantar aspect 
of the right great toe. You note that your pain is exacerbated with weight bearing and ambulation. You also 
state that the right great toe crosses over the right 2nd toe with and without a shoe. You walk with an altered 
gait due to pain. The exam reveals tenderness over the medial first metatarsophalangeal joint and mild 
tenderness over the proximal first tarsometatarsal joint dorsally and medially. However, current peer-reviewed 
literature indicates that further large, randomized, controlled trials are required to support the use of electrical 
bone growth stimulators in the treatment of non-unions. This is especially applicable at this point in time 
(earlier than 9 months post- surgical procedure) and without serial x-rays detailing a lack of any callus 
progression at all. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 non-spinal electrical osteogenesis stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747).