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

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on September 6, 2023. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27096 
provided on September 6, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the drugs (J3490) provided on 
September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87086) provided on June 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87086 is not supported in the medical record. Specifically, per National Coverage 
Determination: Urine Culture (190.12), N31.8 (Other neuromuscular dysfunction of bladder) is not a covered 
diagnosis code for this service. 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 lab services 
(87086) provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651) and garment (E0667).

You asked the Plan to pre-approve an intermittent limb compression device and garment. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A six-month trial of conservative therapy demonstrating failed response to treatment is required.

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 an intermittent limb compression device and garment. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation did not clearly show the patient having tried full conservative treatment efforts for at least 6 months prior to consideration of this 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 intermittent limb compression device and garment have not been met.  Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651) and garment (E0667).
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 LTACH services. You say that the enrollee requires LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for an LTACH admission. 
 
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 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 appears to still be somewhat unstable and requires additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer. 
There are no services at the LTACH that the enrollee requires that are not already available and approved by 
the Plan. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are ready to get discharged and require 
rehabilitation services. The Plan denied your request. The Plan says you do 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary breast cancer panel (81432, 81433) provided on 
April 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that neither the referring physician nor the patient 
had any choice as to where their specimen was to be sent. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 hereditary breast cancer panel (81432, 81433) 
provided on April 13, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1852) and suspension sleeve (L2397) 
provided June 26, 2023. 
 
You asked the Plan to pay for the orthoses. You say that you have attached the supporting documentation. 
Please reprocess the claim.  The Plan denied your request. The Plan says based on Medicare guidelines, the 
knee orthosis and suspension sleeve, requested does not meet the requirements for approval.  
 
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 orthoses. 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 not had recent surgery or a recent injury. The documentation doesnt support 
that the joint is unstable or that there is joint laxity. The requested knee orthosis is not 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for knee orthosis (L1852) and suspension sleeve (L2397) provided June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service June 28, 2023. 
 You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is covered 
by Medicare. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier in the proper location on the claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Specifically, the rules require that this Z-code be reported in the SV101-7 (5010A1-837P) or 
SV202-7 (5010A1-837I) claim line detail field. In this case, you placed the Z code in 24-S (the remarks, line-
level) field. This is not the proper location for this code.  
 
We looked at the file and Medicare rules. 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 lab 
services billed for date of service June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99204 
performed on April 20, 2023, and the acupuncture services coded as 97810, 97811, 97813, and 97814 
performed on April 20, 2023, through June 13, 2023. 
 
You asked the Plan to pay for 99204, 97810, 98711, 98713, and 98714. You say that 99204, 97810, 98711, 
98713, and 98714 should be paid as billed because they are supported in the documentation for all dates of 
service. The Plan denied your request. The Plan says 99204 is denied because payment for this service is 
bundled into payment for 97811, which was billed on the same date, April 20, 2023. 97810 for all dates of 
service in question is denied because payment is bundled into payment for code 97813, billed on the same 
dates. 97811, 97813, and 97814 for all dates of service are denied because they are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and Medicare rules. In this case, we have confirmed that code 97810 is a column two 
code to column one code 97813 with a modifier indicator of 0. The column two code is therefore not payable. 
We have also confirmed that code 99204 is a column two code to column one code 97811. This claim has not 
been billed with an appropriate modifier to bypass the edit. Finally, we confirmed that the provided records do 
not include documentation of personal one-on-one contact with the enrollee for the dates of service in question 
or the re-insertion of any acupuncture needles, as required for reporting codes 97811, 97813, and 97814. Based 
on this information, we decided that Medicare rules for coverage of 99204, 97810, 98711, 98713, and 98714 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services coded as 99204 performed on April 20, 2023, and the acupuncture services coded as 
97810, 97811, 97813, and 97814 performed on April 20, 2023, through June 13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0350U billed for date of service May 26, 2023. 
 
You asked the Plan to pay for the billed service. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the number of units exceed the maximum allowed. 
 
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 must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 0350U is 
1. The MAI value for this code is 2. You billed 1 unit of this code. The Plan has not provided documentation 
that shows more than 1 unit of this code was billed for the day of service at issue. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure code 0350U billed for date of service 
May 26, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an OON provider.  
 
You asked the Plan to pre-approve SNF care. You say that there are no in-network facilities available due to 
the enrollee's isolation requirements. The Plan denied your request. The Plan says the records indicate that the 
enrollee will be out of isolation on December 8, 2023, at which time it is reasonable to expect that an in-
network SNF will be available. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinary tract infection pathogen panel billed with codes 
87481, 87491, 87500, 87563, 87640, 87641, 87653, 87798, and 87641 provided April 14, 2023.  
 
You asked the Plan to pay for a urinary tract infection pathogen panel. You say that this was billed correctly. 
The Plan denied your request. The Plan says this should have been billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a urinary tract infection pathogen panel billed with codes 87481, 87491, 87500, 
87563, 87640, 87641, 87653, 87798, and 87641 provided April 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that K51.40 has an Excludes1 note in relation to K63.5. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on April 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro. 
 
You asked the Plan to pre-approve Neulasta Onpro. 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. 
 
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 Neulasta Onpro. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested use of Neulasta Onpro is 
not FDA-approved for the enrollees diagnosis. It is FDA approved for those with clinically significant 
incidence of febrile neutropenia. In this case, the chemotherapy regimens have intermediate risk of febrile neutropenia of 10-20% based on chemotherapy regimen and does not have one or more risk factors such as age 
greater than 65 years, prior chemotherapy or radiation therapy, persistent neutropenia, bone marrow 
involvement by tumor, recent surgery and/or wounds, liver or kidney dysfunction. The use 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 Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Neulasta Onpro.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver transplant to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a liver transplant.. You say that you are appealing the denial. The Plan 
denied your request. The Plan says there are providers within the network who can provide this service. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a liver transplant to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90791) provided on March 
29, 2023. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 90791 is diagnostic psychiatric evaluation. 
 
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 outpatient mental health services. Our reviewer says that 
the records do not support the billed code. Our reviewer found the procedure report provided does not support the code 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 outpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for outpatient mental health services (90791) provided on March 29, 2023.