Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service March 7, 2023. 
 
You asked the Plan to pay for code 99215. You say that the Plan paid for this code on a different date of 
service, so this claim should pay as well. The Plan denied your request. The Plan says you billed this service 
with an inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of J44.1 and J47.9. Code J47.9 is an Excludes1 code under 
code J44.1, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99215 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99215 billed for date of service March 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 14, 2022, to 
May 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with principal diagnosis code I63.954, described as 
Hemiplegia/hemiparesis following cerebral vascular accident (CVA). We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that documentation does not support the billed code. Our physician reviewer found that the enrollee was 
evaluated for stroke-like symptoms, in the setting of a prior history of stroke (CVA). No evidence of a new 
stroke was identified, and the enrollee was diagnosed with a transient ischemic attack (TIA). As such, I65.954 
is not supported as the principal diagnosis for this hospitalization.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 14, 2022, to May 2, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary computed tomography angiography (CCTA) 
calcium scoring. 
 
You asked the Plan to pre-approve CCTA calcium scoring. You say that the enrollee has risk factors. The Plan 
denied your request. The Plan says this test performed in isolation is considered a screening service and the 
enrollee does not have documented signs, symptoms, or known heart disease.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, CCTA calcium scoring, is considered a screening service. Medicare does not 
cover this test for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
coronary computed tomography angiography (CCTA) calcium scoring.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with ferumoxytol (Q0138). 
 
You asked the Plan to pre-approve ferumoxytol. You say that ferumoxytol is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says ferumoxytol has been prescribed for an off-label, not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 ferumoxytol. Our reviewer says that 
ferumoxytol is not medically reasonable and necessary in this case. Our physician reviewer found ferumoxytol 
is indicated for the treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD). 
Intravenous (IV) iron replacement is preferred over oral replacement in several clinical situations (poor 
gastrointestinal absorption, lack of response to or poor tolerability of oral iron, need for rapid repletion, chronic kidney disease, active inflammatory bowel disease, cancer, chronic or extensive blood loss). In this case, the 
enrollee has a diagnosis of heart failure and there is no documentation of any of the conditions where IV 
ferumoxytol might be indicated. In addition, clinical records do mention that the enrollee has tried oral iron and 
that has failed to improve anemia. The review has determined that the requested use of ferumoxytol is 
not FDA-approved for the enrollees diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with ferumoxytol (Q0138).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy treatment (36415, 99204, Q3014, 96360, 
96523, J9360, J9250, J9260, J3480, J1626, J2506, J1453, J2930, J9060, and J9000) to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve chemotherapy treatment to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
chemotherapy treatment (36415, 99204, Q3014, 96360, 96523, J9360, J9250, J9260, J3480, J1626, J2506, 
J1453, J2930, J9060, and J9000) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on November 29, 2022, by 
an OON provider.  
 You asked the Plan to pay for the psychotherapy visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy visit provided on November 29, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Keytruda is not FDA-
approved for the enrollees diagnosis. Guidelines state treatment up to 24 months and the enrollee has been on 
since August 2020 with stable disease. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single axis, fluid swing and stance phase control 
(L5828), a stance flexion feature (L5845), a fluid stance extension, dampening feature (L5848), an above knee 
or hip disarticulation, knee extension assist (L5850), an addition to lower extremity prosthesis, microprocessor 
control feature, swing and stance phase (L5856), an addition, above knee or hip disarticulation, alignable 
system (L5920), an above knee, knee disarticulation or hip disarticulation, manual lock (L5925), an all-lower 
extremity prostheses, flex-walk system (L5981), a lower extremity prosthesis, not otherwise specified (L5999) 
and a lithium ion battery charger, replacement only (L7368). 
 
You asked the Plan to pre-approve a prosthesis with a computerized knee and advanced foot. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested prosthetics. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a prosthesis with a computerized knee 
and advanced foot. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee improved walking performance 
substantially with the microprocessor knee. These notes were produced in March 2023. He was in a wheelchair 
at the physician evaluation and the physical therapy (PT) notes indicate he functions at a modified independent 
level. The physician notes improved gait speed with the microprocessor knee but does not address whether this 
is with an assistive device or not and he was in a wheelchair at the time of the physician evaluation.  
 The other notes indicate the enrollee is at a modified independent level. Per L33787, there is no evidence the 
enrollee is an advanced ambulator. 
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 prosthesis with a computerized knee and advanced foot have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a single axis, fluid swing and stance phase 
control (L5828), a stance flexion feature (L5845), a fluid stance extension, dampening feature (L5848), an 
above knee or hip disarticulation, knee extension assist (L5850), an addition to lower extremity prosthesis, 
microprocessor control feature, swing and stance phase (L5856), an addition, above knee or hip disarticulation, 
alignable system (L5920), an above knee, knee disarticulation or hip disarticulation, manual lock (L5925), an 
all-lower extremity prostheses, flex-walk system (L5981), a lower extremity prosthesis, not otherwise specified 
(L5999) and a lithium ion battery charger, replacement only (L7368).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
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. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 1, 2022.
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 need rehabilitation due to your clinical needs. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel Sureclick. 
 
You asked the Plan to pre-approve Enbrel Sureclick . You say that the enrollee has had a great response to 
Enbrel. The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare 
Part B coverage. 
 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 Enbrel Sureclick.  
 
Benefits for Enbrel Sureclick  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that it is unclear why the enrollee's needs 
cannot be met with a finger stick glucometer. The criteria for coverage for a CGM require either insulin use or 
low blood sugars; neither criterion are not met in this case. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on January 3, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the wound care services. You say that precertification is not required for these 
services. The Plan denied your request. The Plan says the services were not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care services provided on January 3, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282), purchased on March 1, 2023. 
 
You asked the Plan to pay for the wig. You say that the item should be covered. The Plan denied your request. 
The Plan says this is not a covered item. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282), 
purchased on March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this service, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
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. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
March 8, 2023.