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

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, 83550, and 83970) 
related to end-stage renal disease (ESRD) provided on January 11, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (82728, 83540, 83550, and 83970) related to end-stage renal 
disease (ESRD) provided on January 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix (J9303), to be used with FOLFOX. 
 
You asked the Plan to pre-approve Vectibix. You say that the requested drug is necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says the requested use of Vectibix is not approved by the 
Food and Drug Administration for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vectibix. Our reviewer says that the 
requested use of Vectibix is not medically necessary. Our physician reviewer found the requested use of 
Vectibix is not FDA-approved for the enrollees diagnosis. The reviewer also found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. Therefore, the reviewer found that the requested use of Vectibix is not medically reasonable or 
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 Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix (J9303), to be used with FOLFOX.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve WoundFix. 
 
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 enrollee has a long history of 
bilateral lower extremity ulcers due to venous insufficiency. Her provider indicated that she has not been seen 
in the wound center for at least a year. She has been receiving wound care in the home. She has been treated 
with dressing changes and compression wraps. Her peripheral pulses are not documented. Wound 
measurements dated June 6, 2023, and June 26, 2023 show that both wounds have improved in size over two weeks of wound care. The records do not show that the wound has failed to respond to four weeks of standard 
wound care or that there is adequate blood flow to the lower extremities. WoundFix is therefore 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 pre-approve WoundFix.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for January 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 procedure code 99215 is not supported by the submitted records. 
 
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 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. 
 
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 these services. Our reviewer says that procedure code 99215 is not supported by the submitted records. Our reviewer found the note from the date of service at issue 
describes that the enrollee was seen for a check-up for opioid use disorder without symptoms to report. The 
history was brief and focused. The examination was brief and focused without abnormalities. The enrollee was 
stable and the treatment plan was simple. There was insufficient evidence of a medically appropriate history 
and/or examination or of a high level of medical decision-making to justify the use of code 99215 for this 
encounter.  
 
We looked at this coder'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 procedure code 99215 billed for January 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the medication is medically necessary.  The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Trulicity.  Benefits for Trulicity 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from an IRF to regain their 
independence and have a safe discharge home. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary, and the enrollees can receive the care in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and 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 your arm is still broken, you are not able to walk and 
need therapy services to return to your prior level of function. 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 the intensity of services provided at an IRF. You are not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can 
be met at a lower 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 pre-approve genetic testing (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested genetic testing is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested genetic testing is not a 
covered benefit in the enrollee's clinical situation. 
 
The Plan must follow Medicare rules. Medicare rules say that testing of individuals with no personal history of 
breast, ovarian, fallopian tube, primary peritoneal, pancreatic or prostate cancer is considered screening and is 
excluded by Medicare statute. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the requested genetic testing is BRCA1/BRCA2 
testing. The case record does not support that the enrollee has a personal history of breast, ovarian, fallopian 
tube, primary peritoneal, pancreatic or prostate cancer. Therefore, we decided that the Plan does not have to 
pre-approve genetic testing (81162).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as 82306, 82607 and 82746 
provided November 12, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you were not provided with the correct 
diagnosis codes from the referring provider. You tried to contact the enrollee for correct information but was 
not able to obtain this information timely. The Plan denied your request. The Plan says the claim was received 
after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until February 23, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory service coded as 82306, 82607 and 82746 
provided November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer an acute rehabilitation facility because 
you would like to regain your independence. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that you need to wear a custom compression 
sleeve because it helps with the swelling. The sleeve is recommended as a result of cancer treatment. The Plan 
denied your request. The Plan says the requested sleeve is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as 
noncovered, since it does not meet the definition of a prosthesis. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a mastectomy sleeve have not been met. Policy Article A52478 confirms that a mastectomy sleeve 
is denied as noncovered, since it does not meet the definition of a prosthesis. Therefore, we decided that the 
Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an aortogram with left lower extremity runoff and possible 
intervention (75625, 36246, 75630, 75710). 
 
You asked the Plan to pre-approve an aortogram with left lower extremity runoff and possible intervention . 
You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an aortogram with left lower extremity 
runoff and possible intervention. Our reviewer says that the requested services are considered medically 
reasonable and necessary in this case. Our physician reviewer found there is satisfactory documentation of 
lifestyle limiting claudication in a patient who has undergone left femoral endarterectomy and right iliac artery 
stenting with ankle brachial index (ABIs) that are significantly abnormal and consistent with the symptom 
description.  In addition to the abnormal ABIs, the absence of popliteal and distal pulses is evidence of femoral 
arterial disease.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an aortogram with left lower extremity runoff and possible intervention have 
been met. Therefore, we decided that the Plan has to pre-approve an aortogram with left lower extremity runoff 
and possible intervention (75625, 36246, 75630, 75710).  
 
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: 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 has not been discharged.  
The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 that you have respiratory failure from chronic obstructive pulmonary disease (COPD). The record shows that you were successfully treated with bi-
level positive airway pressure (BiPAP) therapy with average volume-assured pressure support (AVAPS) mode 
in the hospital. The records do not contain sufficient detailed information to justify ventilator treatment. You 
could be treated with a BiPAP machine with AVAPS capability and failure of such a device has not been 
documented. The home ventilator is therefore 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 pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital level of care for laparoscopy surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is needed to ensure the enrollee 
has no internal bleeding. The Plan denied your request. The Plan says inpatient level of care is not medically 
necessary, and this procedure is approvable as outpatient. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the enrollee does not meet criteria for the requested inpatient level of care. Our physician reviewer 
found the records indicate a history of hypertension, remote knee surgery, and inguinal hernia repair. The 
documentation does not indicate significant pre-operative disease, anticipation of a complex surgical approach, 
or a high anesthetic risk. An admitting physician would not reasonably expect the enrollee's necessary hospital 
care to span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital level of care for laparoscopy surgery.
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 the enrollee can tolerate and is expected to benefit 
from intense therapy. The Plan denied your request. The Plan says the enrollee does 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 the enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower 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.