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

 
We decided that the Plan does not have to pre-approve Jelmyto. 
 
You asked the Plan to pre-approve Jelmyto. You say that you are requesting an expedited reconsideration for 
the denial of Jelmyto. You say the enrollee is too frail for surgery and is scheduled for percutaneous 
nephrostomy (PCN) placement next week. The Plan denied your request. The Plan says the requested treatment 
is not considered medically necessary for the enrollee's condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Jelmyto. Our reviewer says that the 
service is not considered medically necessary for the enrollee's condition. Our physician reviewer found 
Jelmyto is only indicated for pyelocaliceal administration for low grade upper tract urothelial cancer. The 
enrollee has high grade upper tract urothelial cancer. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's specific condition. The requested use of Jelmyto is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Jelmyto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Jelmyto.
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 IRF care is medically necessary after surgery. The 
Plan denied your request. The Plan says you do not meet the requirements. The services needed may be 
provided safely in a lower level of care.  
 
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 does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lumbar spine surgery. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81240, 81241, and 81328 rendered on 
December 13, 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 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 the denied codes is: 
 
CPT 81240: 
 
F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant  
CPT 81241: 
 
F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant 
 
CPT 81328: 
 
SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene 
analysis, common variant(s) (eg, *5) 
 
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 the laboratory report documents 
specimen type "Buccal Swab." This procedure is tested with whole blood, and therefore the denied codes 
cannot be verified, as the documentation does not support service billed. 
 
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 procedure codes 81240, 81241, and 81328 rendered on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on March 28, 
2023. 
 
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 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 the denied codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
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 CPT code 96365 and 96366 are 
not supported. The record shows insulin was continuously infused with glucose measurements. There is a more 
specific code to report this procedure. 
 
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 procedure codes 96365 and 96366 rendered on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a power seat elevation 
system (E2300) is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete bilateral noninvasive physiologic studies of upper 
or lower extremity arteries, 3 or more levels provided on August 29, 2022.  
 
You asked the Plan to pay for complete bilateral noninvasive physiologic studies of upper or lower extremity 
arteries, 3 or more levels. You say that the services were medically necessary. The Plan denied your request. 
The Plan says the requested complete bilateral noninvasive physiologic studies of upper or lower extremity 
arteries, 3 or more levels 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 pay for complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels. Our reviewer says that the requested complete 
bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the 
documentation does not support the medical necessity of a multilevel arterial Doppler study. There is no 
documentation of lower extremity symptoms, no documentation of abnormal pulses, and no documentation of 
abnormal ankle-brachial index (ABI) tests. There is no reference to a plan for, or results of the study in the 
patient assessment. The results of the study itself was not provided. If the study demonstrated significant 
peripheral arterial disease, consider resubmitting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of complete bilateral noninvasive physiologic studies of upper or lower extremity 
arteries, 3 or more levels have not been met. Therefore, we decided that the Plan does not have to pay for 
complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels 
provided on August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostate rectal spacer. 
 
You asked the Plan to pre-approve a prostate rectal spacer. You say that the enrollee has prostate cancer that is 
considered high-risk and has opted to undergo androgen deprivation and hypo fractionated external beam 
radiation therapy. You say that since the enrollee does not have visible T3 disease and posterior extension he is 
an excellent candidate for spacer gel placement. The Plan denied your request. The Plan says the cited LCD 
states very clearly that peri-prostatic spacer gel is covered by Medicare only for patients who are in the low or 
favorable intermediate Prostate Cancer Risk Group. This Enrollee's disease is considered high-risk due to his 
grade group 4 tumor. As there no assessment of the prostate by either physical exam or imaging has been 
provided, the size of this enrollee's prostate is unknown. If prostate volume is estimated to be > 80 cc, this 
would be yet another contraindication to placement of peri prostatic. 
 
The Plan follows Medicare rules. Medicare rules say that a prostate rectal spacer is covered when the criteria 
listed in the Medicare rules section of this decision are 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 pre-approve a prostate rectal spacer. Our reviewer 
says that the requested prostate rectal spacer is not considered medically necessary in this case. Our physician 
reviewer found that the records show that the enrollee has stage IIC (high-risk per National Comprehensive 
Cancer Network (NCCN) criteria). Peri-prostatic spacer gel is covered by Medicare only for patients who are in 
the low or favorable intermediate Prostate Cancer Risk Group.  
 
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 prostate rectal spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prostate rectal spacer.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Enhertu (J9358) and Dexamethasone (J1100). 
 
You asked the Plan to pre-approve the services. You say that this regimen is necessary for the treatment of the 
enrollee's condition. The Plan denied your request. The Plan says that there is no literature to support the 
requested regimen in the enrollee's circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested drugs are medically reasonable and necessary. Our physician reviewer found that the enrollee has 
received several prior lines of systemic treatment and has HER2 positive disease. The requested use of these 
drugs is FDA-approved for the enrollee's diagnosis. The requested drugs would be safe and effective and 
otherwise 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve Enhertu (J9358) and Dexamethasone (J1100).  
 
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 drug testing services (procedure code G0483) rendered on 
February 3, 2023. 
 
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 ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management exceeds the needs of the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that testing for 22+ drug classes was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on February 3, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing provided on March 9, 2023.  
 
You asked the Plan to pay for the Guardant360 testing. You say that the provided Guardant360 was medically 
necessary. The Plan denied your request. The Plan says that the provided Guardant360 was not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing may be covered when the 
criteria listed in this decision 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 the Guardant360 testing. Our reviewer says 
that this testing is shown to be reasonable and necessary.  Our physician reviewer found the criteria listed in the 
LCA are met, and there is insufficient tissue for tissue-based 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 the Guardant360 testing have not been met. Therefore, we decided that the Plan 
has to pay for the Guardant360 testing provided on March 9, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional transportation for 
dialysis appointments since you do not have any means of transportation. You also say that you are wheelchair 
bound and require constant assistance and with your dialysis treatments that are 3 times a week. The Plan 
denied your request. The Plan says based on our records, you have exhausted your 2023 transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 1, 
2023, to January 16, 2023. 
 You asked the Plan to pay for SNF care. You say that the services are medically necessary. The Plan denied 
your request. The Plan says there were no daily skilled therapy or nursing needs. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services are not shown to have been required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
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 pay for skilled nursing facility (SNF) care provided from January 1, 2023, to January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87641 rendered on March 7, 
2023. 
 
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 records do not support the services billed. 
 
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 in 
terms of CPT 87640, although the service was reported with modifier -59 - distinct procedural service - the 
laboratory report does not include documentation to support a separate procedure for CPT 87641. Additionally 
for CPT 87641, the medical records do not include a physician order for these services. The denied codes 
cannot be verified. 
 
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 87640 and 87641 rendered on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 rendered on March 15, 2023. 
 
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 these codes are not appropriate for 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 CPT 99152 is "Moderate Sedation provided by the same 
physician or other qualified health care professional performing the diagnostic of therapertic service that the 
sedation supports for patients 5 years of age or older for the first 15 minutes of intraservice time." 
 
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 the medical records provided indicate that CPT 45385 was performed on March 15, 2023, by the same physician who performed the 
moderate sedation services - CPT 99152. CPT 99152 is included in Current Procedural Terminology 45385. 
The rules do allow for the use of an approved modifier to unbundle the relationship between the two codes, 
providing the medical records validate the use of the modifier. In this case, the medical records provided does 
not include sufficient documentation to validate that CPT 99152 was performed as a separate, distinct service, 
independent from CPT 45385. Therefore, it is not appropriate to use a 59 modifier to unbundle these services, 
 
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 procedure code 99152 rendered on March 15, 2023.