Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc or 
Supartz FX. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has not tried and failed the preferred drugs, Orthovisc or Supartz FX. The reviewer 
found that there is no documentation provided indicating that the Plans required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy 
criteria have not been 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma (PRP), and infiltration of a 
sustained release pharmacologic agent for long-acting surgical site pain control. 
 
You asked the Plan to pre-approve PRP treatment. You say that the provider only uses this medication. You 
say that they are unwilling to use any alternatives. You also say that this is the only provider in a 70-mile radius 
that treats temporomandibular joint (TMJ) dysfunction. The Plan denied your request. The Plan says these 
services are not covered. 
 
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 PRP treatment. Our reviewer says that 
the requested PRP treatment is not medically necessary. Our physician reviewer found this is not an approved 
treatment by the Food and Drug Administration (FDA) since there are not enough clinical trials supporting the effectiveness of the treatment. Therefore, the reviewer found that the requested PRP treatment 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 PRP treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma (PRP), and infiltration of a sustained release pharmacologic agent for 
long-acting surgical site pain control.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the services 
are medically necessary. 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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
facility.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided August 5, 2022, to August 6, 
2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the inpatient care was medically necessary. 
The Plan denied your request. The Plan says inpatient level of care is not supported. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  
 
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 inpatient hospital care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee presented to the hospital 
for a tracheal tube exchange which was performed and tolerated without complication. He was able to walk, 
tolerate oral, breath without support, and pain was controlled. Vitals were stable. He was then admitted for 
further observation. This is a request for inpatient hospital care provided on August 5, 2022, to August 6, 2022. 
However, as the enrollee was stable and did not require acute care services following the procedure, and did 
not require complex care or monitoring, observation status would have been sufficient following the procedure. 
Therefore, this request for inpatient care will be considered not medically necessary based on the provided 
documentation. 
 
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 hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care provided August 5, 2022, to August 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided from March 11, 
2023, to April 10, 2023. 
 
You asked the Plan to pay for an oxygen concentrator. You say that you have billed the item at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 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 E1390 is: Oxygen concentrator, single delivery port, 
capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate. 
 
We find that CPT code E1390 is not supported. Specifically, 31 units of the item at issue have been reported. 
However, the item at issue must be billed on a monthly rather than daily basis. Based on this information, we 
decided that Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided 
that the Plan does not have to pay for an oxygen concentrator (E1390) provided from March 11, 2023, to April 
10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 7, 2023. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required for home 
health services. Any claim with incomplete, missing, or invalid information for all of these elements may be 
returned as unprocessable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, we have reviewed the submitted claim. A 
FIPS State and County code has not been reported on the claim. Therefore, we decided that the Plan does not 
have to pay for home health services provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99254 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for procedure code 99254. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
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 99254 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99254 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99254 billed for date of service March 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care to regain strength. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission and, your 
needs can be provided at 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 the complexity of your medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate 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 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 pay for lab services (87150, 87481, 87500, 87640, 87641, 87651, 
87653, 87798, 87801) provided on April 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87150, 87481, 87500, 87640, 87641, 87651, 87653, 87798, 87801) 
provided on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for June 5, 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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only standalone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 for which 
the professional component does not apply. Therefore, we decided that the Plan does not have to pay for 
procedure code 99153 billed for June 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mattress you purchased on June 30, 2023.  
 
You asked the Plan to pay for the mattress. You say that you already purchased this item because you believed 
it would be covered either at 50% or 80%. The Plan denied your request. The Plan says you purchased this 
mattress from a provider who does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the mattress you purchased on June 30, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 18, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this testing was needed to determine the patient's 
eligibility for treatment options. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. The Plan also says that you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. In addition, Medicare rules say that, for lab services, the POS code must reflect the location in 
which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. This 
claim was billed with the laboratory POS code. The records do not support that the sample was taken in a 
laboratory setting. 
 
 Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. 
Therefore, we decided that the Plan does not have to pay for lab testing provided on January 18, 2021.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that complex rehabilitation 
needs that require frequent evaluation by a rehabilitation physician.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry (83789-59) provided on July 18, 2023. 
 
You asked the Plan to pay for 83789-59. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this code is included in code 80307 and is not supported for separate 
payment. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not show that this testing was separate and distinct from the other test 
services performed on this date of service. Based on this information, we decided that Medicare rules for 
coverage of services billed with a -59 modifier have not been met.  Therefore, we decided that the Plan does 
not have to pay for mass spectrometry (83789-59) provided on July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 16, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the lab order does 
not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 6, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services 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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on April 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Palonosetron, Aprepitant, Carboplatin, and 
Paclitaxel. 
 
You asked the Plan to pre-approve Keytruda, Palonosetron, Aprepitant, Carboplatin, and Paclitaxel. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda, Palonosetron, Aprepitant, 
Carboplatin, and Paclitaxel. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug regimen is indicated 
for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug regimen in the enrollee's clinical situation. No literature from Medicare 
approved cancer journals were submitted for review. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Palonosetron, Aprepitant, Carboplatin, and Paclitaxel have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Palonosetron, Aprepitant, 
Carboplatin, and Paclitaxel.