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

 
We decided that the Plan has to pre-approve Trazimera (Q5116), Oxaliplatin (J9263), Dexamethasone (J1100), 
Fluorouracil (J9190), Mvasi (Q5107), and Leucovorin Calcium (J0640). 
 
You asked the Plan to pre-approve Trazimera, Oxaliplatin, Dexamethasone, Fluorouracil, Mvasi, and 
Leucovorin Calcium. You say that the services are necessary. The Plan denied your request. The Plan says that 
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 Trazimera, Oxaliplatin, 
Dexamethasone, Fluorouracil, Mvasi, and Leucovorin Calcium. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the use is supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal. The FDA approved HER2 directed 
therapy for advanced colorectal cancer with HER2+. They approved Tucatinib and Trastuzumab which 
functions in similar pathway as Trazimera. The drug has been through trials showing safety and effectiveness. 
It is reasonable and necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trazimera, Oxaliplatin, Dexamethasone, Fluorouracil, Mvasi, and Leucovorin 
Calcium have been met. Therefore, we decided that the Plan has to pre-approve Trazimera (Q5116), 
Oxaliplatin (J9263), Dexamethasone (J1100), Fluorouracil (J9190), Mvasi (Q5107), and Leucovorin Calcium 
(J0640).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says he services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the member requires additional skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 provided on February 18, 2021. 
 
You asked the Plan to pay for procedure code 64494. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We find that CPT code 64494 is not supported in the medical record. Specifically, this code has a payment 
indicator of N. This means that payment is packaged into payment for other services. No separate payment can be made. Based on this information, we decided that Medicare rules for coverage of procedure code 64494 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 64494 
provided on February 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from August 
1, 2022, to August 4, 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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 reviewer found that the documentation available 
for review that pertains to the appropriate look-back period does not support the enrollees functional score for 
physical therapy/occupational therapy (PT/OT) or skilled nursing. The documentation available for review does 
not support the therapy or nursing levels claimed by the provider. Additionally, there were no records that 
supported an active diagnosis of hypertension or diabetes mellitus with wound care for a surgical wound. The 
1st, 3rd and 4th alphanumeric character in the PDPM were not correct. The partial adjustment to PDPM 
PAYF1 was appropriate. 
 
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 skilled nursing facility (SNF) services rendered from August 1, 2022, to August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology care to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve radiation oncology care. You say that this is medically necessary. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can be treated 
within the Plan network. 
 
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 
radiation oncology care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy-duty power wheelchair (K0858) and 
additional items and accessories (codes E2313, E2377, E1028 x2, E1002, E2300, E2310, E0951 x2, E0955, 
K0108, E1020, and E2623). 
 
You asked the Plan to pre-approve a group 3 heavy-duty power wheelchair and additional items and 
accessories. You say that you do not have anyone who is able to go to appointments with you. You also say 
that this makes it very difficult for you to navigate yourself around the lobby, in and out of elevators, to and 
from the drop off outside the facility with the transportation service. The Plan denied your request. The Plan 
says this request was denied because the records did not show documentation of a seating assessment with 
measurements and reasoning as to why the current wheelchair no longer meets your needs. The Plan also says 
the information submitted on appeal does not meet the guidelines for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with Single Power Option, such as 
code K0858, is covered if the criteria listed in the Medicare rules section of this letter 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 group 3 heavy-duty power wheelchair 
and additional items and accessories. Our physician reviewer found you do not have a neurologic disorder with 
functional deficits. The documentation does not indicate that you have any pressure injuries, require 
intermittent catheterization of the bladder, or have spasticity that would necessitate power tilt or recline. Our 
reviewer found that although your condition may meet criteria for a power wheelchair, the criteria for this 
specifically requested power wheelchair with multiple power options including power tilt and recline are not 
met. 
 
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 group 3 heavy-duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy-duty 
power wheelchair (K0858) and additional items and accessories (codes E2313, E2377, E1028 x2, E1002, 
E2300, E2310, E0951 x2, E0955, K0108, E1020, and E2623).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve the medication. You say that you would like a second shot since the first 
one is no longer effective. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary. The rules also say that the criteria in the LCA listed in 
the Medicare rules section must be 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 the medication. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found no current medical documentation 
supports that the indications for Synvisc-One continue to be met in this case. The documentation provided does 
not indicate that you have had a significant improvement in pain and functional capacity. Lastly, it has not been 
at least 6 months since your last injection. 
 
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 pre-approve Synvisc-One.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need to regain strength before returning home. 
The Plan denied your request. The Plan says a stay at an ongoing inpatient skilled nursing facility is not 
medically reasonable and necessary. 
 
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 pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx assay (81551) provided February 14, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are sole provider for the ConfirmMDx 
test, this test cannot be performed at a contracted laboratory.  The Plan denied your request. The Plan says the 
request for the ConfirmMDx test was not medically necessary on the date of service performed. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show that the ConfirmMDx testing was being done because the 
enrollee was considering repeat biopsy because of persistently elevated Prostate-specific antigen (PSA) and/or 
abnormal digital rectal exam (DRE). ConfirmMDx testing was not medically reasonable and necessary 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for ConfirmMDx assay (81551) provided February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Epifix skin graft. 
 
You asked the Plan to pre-approve the Epifix skin graft. You say that the Epifix skin graft is medical necessary 
to speed up healing of injury that occurred May of 2023. The Plan denied your request. The Plan says the 
requested Epifix skin graft 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 pre-approve the Epifix skin graft. Our reviewer says 
that the requested Epifix skin graft is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Epifix skin graft is not medically indicated. You do not have documentation 
of diabetes and do not meet criteria as outlined. 
 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 Epifix skin graft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Epifix skin graft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging (MRI), lower 
extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences 
(73720-26, LT) provided on March 13, 2023. 
 
You asked the Plan to pay for the MRI. You say that the claim already submitted with appropriate modifier. 
The Plan denied your request. The Plan says the service is not covered as 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. Diagnosis code L97.909 is for a non-pressure 
chronic ulcer of unspecified part of unspecified lower leg with unspecified severity and is not appropriate for 
lines with modifier LT (left) appended. This edit will deny lines when the modifier appended to that line does 
not align with the laterality of the diagnosis it is pointed to per ICD-10CM Guidelines. Based on this 
information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided 
that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging (MRI), lower extremity 
other than joint; without contrast material(s), followed by contrast material(s) and further sequences (73720-26, 
LT) provided on March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from June 21, 2022, to 
June 23, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
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 DRG 640. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was treated for electrolyte disturbances in the setting of lung cancer. There is no evidence that 
the enrollee had acute respiratory failure. As such, the billing of J96.21 is not supported.  
 
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 rendered from June 21, 2022, to June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 93229. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says the documentation provided does not support this service on 
the date in question. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 93229 have been met. 
Specifically, the medical records provided do not include any documentation of any services provided on the 
date in question. Therefore, we decided that the Plan does not have to pay for procedure code 93229 billed for 
date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99214) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visits 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 
office visits (99214) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective covering for a prosthesis (L5964). 
 
You asked the Plan to pre-approve the protective covering. You say that the cover is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. 
 
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 protective covering. Our reviewer 
says that this feature is not medically necessary. Our physician reviewer found the records do not show that the 
prosthesis will be exposed to harsh environments necessitating additional protection beyond what is provided 
with a typical cover. 
 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 protective covering have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a protective covering for a prosthesis (L5964).