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

 
We decided that the Plan has to pay for the chemotherapy treatment with Eribulin provided on November 7, 
2022.  
 
You asked the Plan to pay for the Eribulin treatment. You say that this is medically necessary.  The Plan denied 
your request. The Plan says that this was not medically necessary.  
 
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 Eribulin treatment. Our reviewer says 
that the chemotherapy provided in this case is shown to be medically reasonable and necessary.  Our physician 
reviewer found the enrollee has metastatic breast cancer and has been treated with several agents. The use of 
Eribulin for this condition is FDA-approved. Though usually a taxane should have been tried prior to this 
treatment, the enrollee has been tolerating this treatment with stable disease since February 2022.  
 
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 Eribulin treatment have been met. Therefore, we decided that the Plan has to 
pay for the chemotherapy treatment with Eribulin provided on November 7, 2022.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 28, 2022, to 
November 29, 2022, billed with evaluation and management (EM) codes 99220 and 99217. 
 
You asked the Plan to pay for the practitioner services provided. 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 codes. 
 
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 codes 99220 and 99217 is Initial observation care, per day, for 
the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; and medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit, and Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that coding guidelines do not support the 
use of 99220 and 99217 to be billed together on the same claim as 99217 is a column one code with 99220. 
Medical documentation also does not fully articulate if this enrollee was an observation or not, the enrollee was 
admitted November 28, 2022, and discharged November 29, 2022, but the records are not clear to be able to 
determine if that is accurate for the complete patient stay. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 28, 2022, to November 29, 2022, 
billed with evaluation and management (EM) codes 99220 and 99217.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27216, 27217, and 99223 rendered from 
October 20, 2022, to October 23, 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 the records do not support the services 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. 
 In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 27216: 
 
Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that 
disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum) 
 
CPT 27217: 
 
Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic 
ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral 
superior/inferior rami) 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided documentation from 
this date includes a brief history describing the enrollee having fallen off a ladder requiring intubation. The 
examination had an expanded focus revealing no significant abnormalities. The plan included open reduction 
and internal fixation (ORIF) of the right pelvis of sacroiliac screw, closed reduction of pelvis, nothing by 
mouth (NPO), pain control, and antibiotics. Based on the provided documentation, although the medical 
decision-making was of high complexity, the provided history and physical were each not comprehensive 
enough to justify using CPT 99223.  
 
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 procedure codes 27216, 27217, and 99223 rendered from October 20, 2022, to October 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI testing provided on February 24, 2023.  
 
You asked the Plan to pay for the Guidance UTI testing. You say that the enrollee has a history of chronic 
urinary tract infections (UTIs). The Plan denied your request. The Plan says the service has not been shown to 
be effective for patient management and exceeds the enrollee's needs.  
 
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 Guidance UTI testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided documentation did not clearly show a urinalysis or urine culture 
which is the standard of care for investigating for UTI. There was no explanation as to why polymerase chain 
reaction (PCR) testing was used rather than the standard of care. Current literature does not sufficiently support 
the use of PCR infectious organism testing over urinalysis and culture as it has not shown to lead to improved 
outcomes for this clinical situation. Therefore, this request for Guidance UTI testing will be considered not 
medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Guidance UTI testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guidance UTI testing provided on February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981). 
 
You asked the Plan to pre-approve a flex-walk system. You say that the item is 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. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a flex-walk system (L5981).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance service, basic life support, nonemergency 
transport (A0425, A0428). 
 
You asked the Plan to pay for non-emergent ambulance service. You say that you are requesting that the 
overpayment be corrected. The Plan denied your request. The Plan says payment for these services is not 
allowed separately because it is included in the skilled nursing facility consolidated billing. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of non-emergent ambulance service have not been met. Specifically, the documentation supports that 
the enrollee was in a Part A covered SNF stay on the billed date of service. Payment for the ambulance services 
in the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for 
an ambulance service, basic life support, nonemergency transport (A0425, A0428).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0299). 
 You asked the Plan to pre-approve home health services. You say that the enrollee needs around the clock 
supervision due to her multiple medical problems. She is falling frequently and has low vision. The Plan denied 
your request. The Plan says the 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 enrollee 
has a past medical history of multiple medical comorbidities recently hospitalized with brainstem cerebral 
vascular accident (CVA) now in a home setting. Clinical documentation shows that the enrollee has had 
clinical status change however there is no plan of care to support the medical necessity of a home health aide 
for the treatment of the enrollees illness or injury by the skilled professional staff. 
 
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 (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the provider prescribed a ventilator to help with 
breathing at various times of the day (night and day) because of lung disease. Medicare does not cover a 
ventilator used in this way. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has complicated 
pulmonary status with COPD, obstructive sleep apnea and obesity hypoventilation syndrome. As of August 10, 
2023, she had a good blood gas on bilevel positive airway pressure (BIPAP). The hospital plan was to use 
average volume-assured pressure support (AVAPS). Both are available with a BIPAP machine, and the 
ventilator is not medically necessary. The documentation does not support use of the ventilator rather than the 
BIPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 provided on March 7, 2023. 
 
You asked the Plan to pay for procedure code 93970. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim line cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed with the GZ modifier will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. This claim line was billed with modifier GZ. Based on this 
information, we decided that Medicare rules for coverage of procedure code 93970 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93970 provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 19, 2022, billed with 
codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87640, 87641, 87651,87653, 87661, 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says panel testing should be billed using 
one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 19, 2022, billed with codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87640, 87641, 
87651,87653, 87661, 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
2, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 1-7 drug classes (G0480) 
provided September 8, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you could not submit the claim on time due 
to the global pandemic. 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 October 21, 2022. 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 definitive drug testing, 1-7 drug classes (G0480) provided 
September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spinal fusion, laminectomy, facetectomy and 
foraminotomy. 
 
You asked the Plan to pre-approve a lumbar spinal fusion, laminectomy, facetectomy and foraminotomy. You 
say that the patient is in a lot of pain and uses a cane for mobility. You say the patient has tried therapy, 
injections and pain management with no relief. The Plan denied your request. The Plan says there is no refuting 
the denial rationale and the records show failed treatments without detailed weeks and adequate exercise 
therapy such as stationary bicycling.  
 
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 lumbar spinal fusion, laminectomy, 
facetectomy and foraminotomy. Our reviewer says that the requested lumbar spinal fusion, laminectomy, facetectomy and foraminotomy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no recent and adequate trial of physical therapy for back pain. More 
conservative measures are needed. 
 
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 lumbar spinal fusion, laminectomy, facetectomy and foraminotomy have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spinal fusion, 
laminectomy, facetectomy and foraminotomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6010, A6197, A6219) provided on 
February 24, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says these items were provided in a SNF setting and are not separately 
payable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies was used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for wound care supplies (A6010, A6197, A6219) provided on February 24, 2023.