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

 
We decided that the Plan does not have to pay for the blood smear and interpretation billed with code 85060 for 
September 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Procedure code 85060 has a PC/TC indicator of 8 and the file shows 
that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does not have 
to pay for the blood smear and interpretation billed with code 85060 for September 4, 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 enrollee has high risk factors for bone fractures. 
You also say that the requested drug is medically necessary for the enrollee. The Plan denied your request. The 
Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Prolia is allowed when the oral health of the patient 
was discussed, and the patient was instructed to take 1,000 mg of calcium and at least 400 IU of vitamin D per 
day. 
 
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 
request for Prolia is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has taken 1,000 mg of calcium and at least 400 international unit (IU) of vitamin 
D per day or that the oral health of the enrollee was discussed. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for muscle or tendon transfer, any type, upper arm or elbow, single 
provided to the enrollee on October 20, 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 that the records do not support the services 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 24301 is "Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was being treated for 
primary osteoarthritis of the right shoulder, recurrent dislocation of the right shoulder, and contracture of the 
right shoulder. He underwent a right reverse total shoulder arthroplasty; anterior and posterior capsule 
contracture release; single muscle transfer of the long head of the biceps to the pectoralis major on 10/20/22. 
The operative procedure detail cites the bicipital sheath was then identified. The transverse fascia was sharply 
incised. The fascia was then split into the rotator interval. The retained biceps were then transferred to the 
pectoralis major with a total of 3 figure of 8 #2 sutures. The transfer was concluded of the biceps tendon to the 
pectoralis major. Therefore, the records do support that CPT 24301 was rendered in this case.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
muscle or tendon transfer, any type, upper arm or elbow, single provided to the enrollee on October 20, 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 pay for inpatient hospital services provided on February 06, 2022, 
through February 11, 2022, and billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code A41.9, Sepsis, unspecified 
organism. 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 the documentation does not support the primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the member was febrile, had leukocytosis, and normal platelets. 
The provided documentation does not show that the member had a dysregulated host response from a systemic 
infection with organ damage. With that being said, the member does not meet the Sepsis III criteria. Therefore, 
the diagnosis code, A41.9 Sepsis, unspecified organism is not the appropriate primary 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 hospital services provided on February 06, 2022, through February 11, 2022, and billed with 
diagnosis code A41.9.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued skilled nursing facility (SNF) care beyond 
February 16, 2023. 
 
You asked the Plan to approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to approve SNF care. Our reviewer says that the 
continued SNF services are not medically necessary. Our physician reviewer found you were admitted to the 
SNF on January 20, 2023 and received antibiotics. The documentation states you are walking 250 feet with 
limited assistance. There are no reports from physical or occupational therapy. The records do not support that 
you have any daily skilled nursing needs. The records do not support that you have daily skilled therapy needs. 
As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to approve continued skilled nursing facility (SNF) care beyond February 16, 2023.
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 stable and ready for 
transfer to an LTACH. You say that the enrollee's needs aggressive physical and occupation therapy to regain 
maximum level of function. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zephyr valve procedure and associated inpatient 
hospital stay. 
 
You asked the Plan to pre-approve a Zephyr valve procedure and associated inpatient hospital stay. You say 
that you have a hard time breathing, are on oxygen, and having a hard time with day-to-day functions. You also 
say that surgery would help you get back to a better base line. The Plan denied your request. The Plan says this 
request 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 a Zephyr valve procedure and 
associated inpatient hospital stay. Our reviewer says that a Zephyr valve procedure and associated inpatient 
hospital stay are not considered medically reasonable and necessary in this case. Our physician reviewer found 
your body mass index is 36.74. Our reviewer also found that the Zephyr valve procedure is not medically 
reasonable or necessary. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Zephyr valve procedure and associated inpatient hospital stay have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Zephyr valve procedure and associated 
inpatient hospital stay.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says this drug is not covered under the patient's medical benefits.  The Plan says 
that it has tried multiple times to get clarifying information from you with no response. 
 
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. It appears as though you are requesting an anti-emetic drug.  Certain anti-emetic drugs are 
coverable under Medicare Part B.  However, you have not provided sufficient documentation to show that this 
drug meets Part B coverage criteria.  The Plan has requested information from you to clarify if the requested usage of this drug meets criteria, but you have not responded to those requests. Therefore, we decided that the 
Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron 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 pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request cannot 
be approved at this time because the records do not show the criteria for coverage have been met. 
 
 
 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 Euflexxa. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Euflexxa. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no 
indication that the Plan's required drugs 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940 x 2) 
provided on October 25, 2022 and November 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as manual 
manipulation of the spine was not performed. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. Additionally, the rules say for Medicare to consider 
coverage and payment for any item or service, the information submitted by the supplier or provider must 
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage 
criteria have been met. 
 
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 these services. Our reviewer says that the 
services provided do not meet criteria for coverage. Our physician reviewer found that in this case, the record 
indicates that you have a diagnosis of a subluxation of the spine. However, the provided records do not 
document the performance of manual manipulation of the spine. Therefore, the elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatments (98940 x 2) provided on October 25, 2022 and  
November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests (80307, G0480) provided on October 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug tests. You say that this claim should be covered. The Plan denied your 
request. The Plan says these services are not covered when provided OON without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug tests (80307, G0480) provided on 
October 7, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have severe pain in your legs from leg burns and 
are needing rehab. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and the services you need can be provided safely in other settings. 
 
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 your nursing, medical and rehabilitation needs do not require 
an acute hospital stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are 
stable on outpatient medications with no issues that require a physicians evaluation three or more times per 
week in a hospital setting. Treatment such as outpatient therapy, home health therapy or a skilled nursing 
facility are more appropriate. 
 
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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
segmental pneumatic appliances (E0673) provided July 25, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided segmental pneumatic appliances (E0673) provided 
July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens are received from providers. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Codes 83520 and 87798 describe codes not 
otherwise specified. The claim does not indicate what tests these codes coincide with. 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 the lab services provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on March 23, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary and appropriate. 
The Plan denied your request. The Plan says this is not an approved, Medicare-covered test. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the service 
requested is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair to be provided by an out-of-network (OON) provider.