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

 
We decided that the Plan does not have to pay for the medical supplies and contrast agent used during a 
medical service on November 22, 2022, billed with codes A4615, A4616, and A9579. 
 
You asked the Plan to pay for the supplies and contrast agent. You say that this should be paid in full.  The Plan 
denied your request. The Plan says the A-codes billed are not payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that services that are integral 
to a procedure should not be separately reported.  
 
The CPT manual definition of A9579 is injection, gadolinium-based magnetic resonance contrast agent, not 
otherwise specified (nos), per ml. A4615 is cannula, nasal, and A4616 is tubing, oxygen, per foot. 
 
We looked at the file and Medicare rules. The use of nasal cannula and oxygen tubing is an integral part of the 
procedures provided on this date of service and should not be separately reported. As for code A9579, the 
documentation shows that an injection of Dotarem (gadoterate) was used. There is a more specific code for this 
agent. Based on this information, we decided that Medicare rules for coverage of the supplies and contrast 
agent have not been met. Therefore, we decided that the Plan does not have to pay for the medical supplies and 
contrast agent used during a medical service on November 22, 2022, billed with codes A4615, A4616, and 
A9579.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair, multiple power option 
(K0861). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you reviewed the submitted notes and 
documentation and believe the wheelchair should be covered. The Plan denied your request. The Plan says the 
enrollee does not have medical need for multiple power options included with K0861 group 3 power 
wheelchair. As the requested Group 3 Power Wheelchair is not reasonable and necessary, none of the requested 
accessories can be covered.  
 
The Plan must follow Medicare rules. The rules say that if a Group 3 Single Power Option or Multiple Power 
Options PWC is provided and if criterion is not met, it will be denied as not reasonable and 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 the power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records do not support that the enrollee is high risk for skin breakdown 
(physician's exam reports strength as 4/5 to 5/5 with intact sensation), has a history of pressure ulcer(s) or has 
had skin flap surgery. The records do not document the enrollee performs bladder self-catheterization or that 
the enrollee has increased muscle tone or spasticity to meet criteria for the power tilt and/or recline and thus the 
multiple power option base. As the requested wheelchair base does not meet Medicare coverage criteria, the 
requested accessories are not covered.   
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Group 3 power wheelchair, multiple power option (K0861).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) testing (84443) 
provided April 19, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the physician saw these tests as medically 
needed to continue care and monitor progress. The Plan denied your request. The Plan says procedure code 
84443 has n met the associated diagnosis code relationship criteria per NCD 190.22. 
 
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. The claim was billed with diagnosis code F10.20: Alcohol 
dependence, uncomplicated. This is not a covered diagnosis for this test. Based on this information, we decided 
that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the thyroid stimulating hormone (TSH) testing (84443) provided April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection for a Group 3 power 
wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records document that the enrollee 
has five out of five upper extremity strength and is independent with eating. He has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. The electronic 
connection is not medically necessary based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve an electronic connection for a Group 3 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for procedure code 87798 billed for date of service May 
18, 2023. 
 
You asked the Plan to further pay for the billed services. The Plan denied your request. The Plan says the 
number of units is not supported. 
 
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 the rules. The file shows that 19 units of code 87798 were billed. The Plan agreed to 
pay for 6 units. The records do not support 13 additional targets being tested. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to further pay for procedure code 87798 billed for date of service May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 8 units of code J1100, defined as injection, dexamethasone 
sodium phosphate, 1 milligram, billed on August 23, 2022. 
 
You asked the Plan to pay for J1100. You say that 8 units of code J1100 should be paid as billed because they 
are supported in the medical record. The Plan denied your request. The Plan says 8 units of code J1100 are 
denied because they are not supported in the medical 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. The National Drug Code (NDC) associated with J1100 reported on 
the claim does not match the NDC reported in the medical records for the same services. Due to this 
discrepancy, we are unable to confirm if the number of units or dosage reported on the claim was correct. 
Therefore, 8 units of code J1100 are not supported. Based on this information, we decided that Medicare rules 
for coverage of J1100 have not been met. Therefore, we decided that the Plan does not have to pay for 8 units 
of code J1100, defined as injection, dexamethasone sodium phosphate, 1 milligram, billed on August 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra (J3262). 
 
You asked the Plan to pre-approve the drug. You say that you have temporal arthritis and if the medication is 
not approved then you will have no choice but to be put in the hospital. You say that you are on a large dose of 
prednisone and without the requested drug you will be on the steroid for a minimum of one year. 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 Actemra (J3262). 
 
Benefits for the drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service June 8, 2023. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says code 99153 is not 
payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. The claim was billed with an inpatient hospital 
place of service code. There is no separate payment to the physician for CPT code 99153 when performed in 
the facility setting. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for date of service June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on May 17, 2023. 
 
You asked the Plan to pay for drugs or medicaments dispensed in the office for home use (D9630). You say 
that this was denied and has to be covered. You also say you received a bill from the provider. The Plan denied 
your request. The Plan says there is no coverage for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments dispensed in the office for home use (D9630) provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001x25 units). 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says the requested service does not meet the coverage 
criteria. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found usually image guided radiation therapy (IGRT) is used when critical structures are 
abutting or in close proximity to the target that is being treated to high doses. This situation does not apply to 
this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is Food and Drug 
Administration (FDA) approved for use with ultrasound though that in and of itself does not mean that daily 
imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill 
for daily simple simulations and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines (many of which recommend against treatment with these 
devices in general) is not necessary. The decision is unfavorable as billing for daily IGRT which would not be 
"furnished in accordance with accepted standards of medical practice". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasonic guidance for placement of radiation therapy fields (G6001x25 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Caris Molecular Intelligence Tumor profiling (ALK and 
PTEN identified with code 88360 X2). 
 
You asked the Plan to pre-approve ALK and PTEN testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ALK and PTEN testing are only covered for certain 
indications. 
 
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 ALK and PTEN testing. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has stage IV breast cancer. The documentation does not support 
required testing nor its medical necessity. Therefore, the enrollee does not meet criteria for the requested 
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 ALK and PTEN testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Caris Molecular Intelligence Tumor profiling (ALK and PTEN identified with 
code 88360 X2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation. You say that if the procedure is not 
approved, it can seriously jeopardize the enrollee's ability to regain maximum function. The Plan denied your 
request. The Plan says the request is not medically necessary because the records do not show documentation 
of any urodynamic studies that may have been performed and the enrollee do not meet the age criteria for this 
procedure. 
 
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 transurethral waterjet ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not meet criteria for approval of waterjet ablation of the 
prostate. The records do not provide a prostate symptom score, the enrollee is over 80 years old, and the 
records do not show a maximum urinary flow rate (Qmax) of =15 milliliters (voided volume greater than 
125cc). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower overdenture (D5865). 
 
You asked the Plan to pre-approve a complete lower overdenture. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete lower overdenture (D5865).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 20, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 20, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
20, 2023, forward. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
as of the last covered day, there is no indication in the available medical records that the enrollee's psychiatric 
symptoms could not be managed on a less restrictive basis. As of the last covered day the enrollee did not 
express any active suicidal ideation or intent, or any intent to harm themselves or anyone else. The enrollee was 
not exhibiting any other significant symptoms such as mania. The enrollee had no acute psychiatric issues that 
would require continued inpatient care beyond the last covered day. The enrollee has chronic symptoms. The 
available medical records do not support that continued inpatient care will change these symptoms or the 
enrollees current 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 inpatient psychiatric care from October 20, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 20, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service June 2, 
2023. 
 
You asked the Plan to pay for procedure code A4550. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code A4550 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
A4550 billed for date of service June 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing rendered on April 11, 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 testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that minimal residual disease (MRD) testing is 
covered when specific criteria 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 pay for these services. Our reviewer says that the 
testing was not medically necessary. Our physician reviewer found the Guardant Reveal test was used to detect 
circulating tumor DNA (ctDNA) and is used as a surveillance test to detect early disease relapse. There was no 
ctDNA detected for this enrollee. The records do not support that the criteria for coverage are met. The testing 
was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant Reveal testing rendered on April 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Opdualag. 
 
You asked the Plan to pay for the medication. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the requested use of this drug combination is not supported. 
 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 pay for the medication. Our reviewer says that the 
requested drug combination is not supported. Our physician reviewer found that the requested use of Opdualag 
in combination with Avastin is not FDA approved for the enrollees diagnosis and is not supported by one of 
the major drug compendia or by clinical research. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pay for the Opdualag.