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

 
We decided that the Plan does not have to pay for Tempus xT (81455) provided on February 22, 2023. 
 
You asked the Plan to pay for Tempus xT. You say that this test was necessary and appropriate. The Plan 
denied your request. The Plan says this test was 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 pay for Tempus xT. 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 early-stage breast cancer and does not have either recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer, which is one of the NCD criteria by Medicare of Next 
Generation Sequencing (NGS) testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xT have not been met. Therefore, we decided that the Plan does not 
have to pay for Tempus xT (81455) provided on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disposable drug delivery system. 
 
You asked the Plan to pre-approve disposable drug delivery system. You say that you need this. The Plan 
denied your request. The Plan says disposable drug delivery systems are excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are not covered 
by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of disposable drug delivery system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a disposable drug delivery system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PBRT. 
 
You asked the Plan to pre-approve PBRT. You say that this therapy is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no compelling data to suggest that proton therapy is superior to or more beneficial 
than intensity-modulated radiation therapy or image-guided radiation therapy. The generally accepted standard 
of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to 
patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve PBRT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to improve 
functional mobility, daily living skills, and gait. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for admission to an IRF. 
 
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 the enrollee is medically stable. The enrollee does not need specialized and intensive 
therapies. The enrollee's rehab needs are more appropriate for an alternate and low intensity setting such as in a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hyperbaric oxygen under pressure, full body 
chamber (G0277 and 99183). 
 
You asked the Plan to pre-approve the services. You say that it is medically necessary.  The Plan denied your 
request. The Plan says  the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the hyperbaric oxygen treatment at issue in this case meets all 
Medicare criteria for medically reasonable and necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the hyperbaric oxygen under pressure, full body chamber (G0277 and 99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 20, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 20, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87150, 87798 and 87481) provided on April 11, 
2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services were not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has cited a rule which does not have jurisdiction over state 
where these services were performed, and we were unable to find this information in a determination which 
applies to the state in question. In addition, the services at issue were each reported with the -59 modifier, 
indicating that they were provided as separate and distinct services. It does not appear that the Plan has 
performed a review to determine whether the reported modifiers were appropriate or not. The Plan has not fully 
substantiated their denial in this case. Therefore, we decided that the Plan has to pay for laboratory services 
(87150, 87798 and 87481) provided on April 11, 2023.  
 
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 Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the services are medically necessary. 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 may cover the use of an FDA-approved drug 
or biological if it is safe and effective and otherwise reasonable and necessary for the patient. Food and Drug 
Administration (FDA) approved drugs used for indications other than what is indicated on the official label 
may be covered if the use is determined to be medically accepted, taking into consideration the major drug 
compendia, authoritative medical literature and/or accepted standards of medical practice. You can find this 
rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare 
Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2. 
 
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 Procrit. Our reviewer says that Procrit 
is not medically necessary. Our physician reviewer found to use Procrit, the enrollee's hemoglobin blood count 
needs to be below 10 grams per deciliter. The use of Procrit is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The request for Procrit 
cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve breast MRI. You say that after surgery you developed a blood clot. The Plan 
denied your request. The Plan says this MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 breast MRI. Our reviewer says that you 
do not meet criteria for this MRI. Our physician reviewer found there is no documentation of inconclusive or 
abnormal mammogram or breast ultrasound. There is no documentation of abnormal findings on breast exam 
or suspicion of ruptured silicone breast implants. Therefore, this MRI is not 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 breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the breast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation, revision or repositioning of tunneled 
intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable 
reservoir/infusion pump; without laminectomy (62350) and Putty Isotis Allograft (20930).  
 
You asked the Plan to pre-approve implantation, revision or repositioning of tunneled intrathecal or epidural 
catheter and Putty Isotis Allograft. You say that this service is medically necessary. The Plan denied your 
request. The Plan says there is no information regarding the need for placing a catheter in the enrollees spine. 
 
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 implantation, revision or repositioning of tunneled intrathecal or epidural catheter and Putty Isotis Allograft. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that the above noted procedures 
meet all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records in this case 
document the need for "removal of posterior hardware at L4-5 with L2-3 and L3-4 decompression with fusion 
with instrumentation," but records do not address and do not document necessity of the implantation, revision 
or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an 
external pump or implantable reservoir/infusion pump; without laminectomy (62350) and Putty Isotis Allograft 
(20930) as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation, revision or repositioning of tunneled intrathecal or epidural 
catheter and Putty Isotis Allograft have not been met. Therefore, we decided that the Plan does not have to pre-
approve implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term 
medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 
(62350) and Putty Isotis Allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87486, 87498, 87502, 87581, 87633, 
87634, 87640, 87651, 87798, U0003 and U0005) billed for date of service December 1, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
laboratory services (87486, 87498, 87502, 87581, 87633, 87634, 87640, 87651, 87798, U0003 and U0005) 
billed for date of service December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you are seeking review for the services. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13 The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 27, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that the services 
requested are medically necessary. The Plan denied your request. The Plan says that the criteria for approval 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 positron emission tomography (PET) 
scan. Our reviewer says that the service is medically 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 positron emission tomography (PET) scan have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) scan.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelstar Mixject for suspension 11.25mg. 
 You asked the Plan to pre-approve Trelstar Mixject for suspension 11.25mg. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 Trelstar Mixject for suspension 
11.25mg. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee has not tried and failed the required drug. There is no documentation provided indicating that the 
would plan's required drug 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 Trelstar Mixject for suspension 11.25mg have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Trelstar Mixject for suspension 11.25mg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service July 20, 
2022.  
 
You asked the Plan to pay for procedure code 95861. You say that you have billed the services at issue 
correctly. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service July 20, 2022.