Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that due to the enrollee's condition it is preferred to use 
Xgeva over Zometa. The Plan denied your request. The Plan says the Plan requires a trial of Zometa before it 
will approve Xgeva. 
 
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 Xgeva. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Xgeva. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Zometa. The record does not show that this drug 
would be less effective and/or 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says code 99223 is not supported by the medical record because the 
records don't support a comprehensive history. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the enrollee was a then 93 year old male with a history of 
atrial fibrillation/ flutter, hypertension, pulmonary hypertension, diabetes mellitus, chronic kidney disease, 
benign prostatic hypertrophy, and nephrolithiasis who presented to the emergency room on July 05, 2022, with 
a 3 week history of shortness of breath. Current Procedural Terminology (CPT) code 99223-AI (1 unit) was not 
supported. This initial hospital care evaluation and management code requires a comprehensive history, a 
comprehensive examination and medical decision making of high complexity. In this case, the medical records 
submitted did not support a comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service July 5, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee had functional and clinical status changes with multiple medical events, 
with electrolyte derangement, orthostatic hypotension, and acute functional impairments. He requires 
assessment by skilled therapy and skilled nursing. The records show that the enrollee is at maximal assist for 
transfers, toileting, and evaluating. The skilled therapists and primary team recommend skilled therapy in the 
SNF setting. The enrollee has wounds, a feeding tube, and labile blood pressure that requires skilled nursing on 
a daily basis. As a practical matter, the enrollee requires daily skilled services on an inpatient basis at the SNF. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided November 25, 2021, to 
December 2, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that these services have been correctly denied. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record shows 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided November 25, 2021, to December 2, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on December 14, 2022. 
 
You asked the Plan to pay for contact lenses. You say that you purchased the contacts in December 2022 via  
1-800-Contacts as your optometrist could not provide them and you feel it is irrelevant where you purchased 
the contacts as you have a $100 eye wear benefit. The Plan denied your request. The Plan says the benefit plan 
does not cover this out-of-network vision care service/material. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when you use the Plans vision care provider. 
 
We looked at the file and the Plan's rules. The file shows that the contact lenses were not provided by the 
Plans vision care provider. Based on this information, we decided that the Plan's rules for coverage of contact 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses provided 
on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 9, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says a valid DEX Z-code was 
not billed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional continuous glucose monitor (CGM) supplies 
(A4239). 
 
You asked the Plan to pre-approve A4239. You say that you need more supplies than what the Plan approved. 
The Plan denied your request. The Plan says the Plan already approved a 90-day supply of CGM sensors so 
additional sensors cannot be approved at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than a 90-day supply of CGM supply 
code A4239 may be dispensed to a beneficiary at a time.  
 
We looked at the file and Medicare rules. The Plan has already approved a 90-day supply for your CGM. 
Additional supplies cannot be dispensed to you at this time. Based on this information, we decided that 
Medicare rules for coverage of A4239 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve additional continuous glucose monitor (CGM) supplies (A4239).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia ClickJet injections. 
 
You asked the Plan to pre-approve Orencia ClickJet injections. You say that the enrollee is currently on 
maximal doses of methotrexate and Humira and is still having breakthrough inflammatory polyarthritis. You 
say that the enrollee has been unable to be tapered off of steroids and has osteopenia. You say that Orencia is a 
great option to help reduce the enrollee's overall systemic steroid burden. You say that the enrollee is not a 
candidate for JAK inhibitors or IL-6 inhibitors because of her thromboembolic risk and is on Xarelto. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan.  
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 Orencia ClickJet injections.  
 
Benefits for Orencia ClickJet injections 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on  
October 13, 2022. 
 
You asked the Plan to pay for the office or other outpatient visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services 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 an office or other outpatient visit provided on October 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 16, 2022, to 
February 14, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 16, 2022. The NOA was not received by the Plan until January 18, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 16, 2022, to February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on August 6, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted 
delivery ticket is not itemized to show that the items in question were delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the supplies provided on August 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the enrollee needs a medical bed 
because the top of the bed must be elevated due to the enrollee's COPD. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the requested hospital bed because he does not 
weigh between 350 and 600 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested heavy-duty hospital bed is covered 
if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more 
than 350 pounds but does not exceed 600 pounds.   
 
 We looked at the file and Medicare rules. Medicare rules say the requested bed is covered if the enrollee 
weighs more than 350 pounds but does not exceed 600 pounds. The records show the enrollee weight is 
between 290 and 300 pounds, therefore, the enrollee does not meet criteria for approval. Based on this 
information, we decided that Medicare rules for coverage of a heavy-duty hospital bed have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with 
weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type of side rails, with 
mattress (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
October 19, 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 the documents do not support this level of care. 
 
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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 not supported by the medical records. Our reviewer found that based on the provided note, there 
was a detailed history but only focused exam and no medical decision-making of moderate complexity but 
rather of low complexity. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99222) rendered on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xf genetic testing (81455) provided October 31, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this 
determination and coverage of the Tempus Liquid Biopsy CGP panel test at the in-network benefit level. The 
Plan denied your request. The Plan says the requested test is not reasonable and necessary because Tempus xF 
has not had FDA approval or clearance as a companion in vitro diagnostic or an FDA-approved or -cleared 
indication for use in this enrollees cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of bladder Cancer. There is no 
documentation of metastatic disease. The review has determined that the medical records provided did not meet 
the requirements listed in the NCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Tempus xf genetic testing (81455) provided October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myopro brace. 
 
You asked the Plan to pre-approve Myopro brace. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device 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 Myopro brace. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has multiple sclerosis with left upper extremity weakness. The MyoPro Orthosis is 
not known to be effective, based on scientific evidence, professional standards and expert opinion, in 
improving health outcomes. The MyoPro is not the standard of care for this enrollee's multiple sclerosis 
condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee. 
There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 
Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myopro brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Myopro brace.