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

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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.  
 
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 Reblozyl. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has myelodysplastic syndrome. The accepted use of this drug for  the enrollee's 
condition requires ring sideroblasts greater than or equal to 15% (or ring sideroblasts with greater than or equal 
to 5% with a SF3B1 mutation). The enrollee does not meet these requirements. Therefore, the enrollee does not 
meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported retainer for tooth 10 (D6068), 
custom abutment tooth 10 (D6057), and implant supported retainer for tooth 11 (D6075). 
 
You asked the Plan to pre-approve abutment supported retainer for tooth 10, custom abutment tooth 10, and 
implant supported retainer for tooth 11. You say that the services are necessary. The Plan denied your request. 
The Plan says the requested services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve abutment supported retainer for tooth 10 (D6068), custom abutment tooth 10 (D6057), and implant supported 
retainer for tooth 11 (D6075).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visits provided from October 7, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay for the domiciliary services provided from October 7, 2022, to October 31, 2022.. 
You say that this claim should be reprocessed under the level 5 Hospice Care benefit. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 find that the documentation does not 
support that any services took place beyond October 6, 2022. The enrollee passed away on this date, so no 
payment can be made for the dates beyond the date of death. Therefore, we decided that the Plan does not have 
to pay for the domiciliary visits provided from October 7, 2022, to October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on September 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary. The Plan 
denied your request. The Plan says these services were not provided or referred by participating providers. Out-
of-network care is covered only in certain limited circumstances which have not been met in this case. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided and/or requested the items/services at issue in this appeal. The Plan did not 
pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) 
provided on September 27, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry, per 
specimen; each multiplex antibody stain procedure (88344) provided on May 17, 2022. 
 
You asked the Plan to pay for immunohistochemistry or immunocytochemistry. You say that this service was 
medically necessary. The Plan denied your request. The Plan says IHC staining would not be expected to yield 
additional information that would change treatment decisions. 
 
The Plan follows Medicare rules. Medicare rules say that this testing may be covered when it is medically 
reasonable and necessary and meets the criteria for coverage in the rules section of this letter. 
 
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 immunohistochemistry or 
immunocytochemistry. Our reviewer says that this service does not meet criteria for coverage. Our physician 
reviewer found that more than 50 % of the tissue of the right lateral mid has grade group 3 disease. IHC 
staining would not be expected to yield additional information that would change treatment decisions. Thus, the 
testing is not considered medically reasonable and 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 immunohistochemistry or immunocytochemistry have not been met. Therefore, 
we decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry, per 
specimen; each multiplex antibody stain procedure (88344) provided on May 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-miles limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation to medically necessary testing. The Plan denied your request. The Plan says the requested trip 
exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 50 miles of driving distance. 
 
We looked at your request, the records in the case file, and the rules. The requested trip in this case is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-miles limit.
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 is stable and safe for 
discharge to an LTACH. You say that an admission to an LTACH can help the enrollee improve their condition 
and avoid readmission to a short-term acute care hospital. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee's needs can be provided in another setting. 
 
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 is improving but still is unstable and only requires short-term acute 
care at the current facility until they are more stable. The enrollee does not require services at the LTACH that 
are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87500 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 87500. You say that this service is supported as billed. The Plan 
denied your request. The Plan says this service is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87500 is infectious agent detection by nucleic acid (DNA 
or RNA; vancomycin resistance (e.g., enterococcus species van A, van B), amplified probe technique. 

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 procedure code 87500. Our reviewer says that this code is 
not supported in the medical records provided. Our reviewer found the laboratory report does not include 
documentation of infectious agent by nucleic acid, vancomycin resistant. This procedure and results were not 
included in laboratory report and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87500 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87500 billed for date of service October 27, 2022.
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 records do not show that you have failed 
treatment with CPAP or BIPAP or that the requested NIV will not be used exclusively in CPAP or bi-level 
PAP mode. The request is 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the 
Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 4 power wheelchair (K0884) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
is medically necessary. The Plan denied your request. The Plan says that a Group 4 power wheelchair is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 4 PWCs have added capabilities that are 
not needed for use in the home. 
 
We looked at the file and Medicare rules. Group 4 PWCs are not covered by Medicare. As the PWC base is not 
covered, the requested accessories are also not covered. Therefore, we decided that the Plan does not have to 
pre-approve a Group 4 power wheelchair (K0884) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies (A4239). 
 
You asked the Plan to pre-approve CGM supplies. 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. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 CGM supplies have been met. 
Specifically, additional clinical information was requested but not received. Medical necessity cannot be established without this documentation. Therefore, we decided that the Plan does not have to pre-approve 
continuous glucose monitor (CGM) supplies (A4239).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2022, billed 
with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
December 2, 2022, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 81334.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29581 and 99335 billed for date of service 
September 14, 2022. 
 
You asked the Plan to pay for procedure codes 29581 and 99335. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed for code 
29581 and code 99335 was billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29581 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 29581 and 99335 have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for code 99335 was incorrectly billed with POS code 32 
for a nursing facility. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 29581 and 99335 billed for date 
of service September 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 26, 
2022, through April 24, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says ongoing skilled care could have been provided in an alternate setting. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing 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 pay for skilled nursing facility (SNF) care provided from March 26, 2022, through April 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on November 19, 2021, 
through November 24, 2021, and billed with diagnosis code N17.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code N17.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support primary diagnosis of N17.9. 
 
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 secondary diagnosis code N17.9 Acute kidney 
failure, unspecified. 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 documentation does not support the primary 
diagnosis of N17.9 Acute kidney failure, unspecified. Our physician reviewer found the member was 
hospitalized with a post-operative infection.  The members creatinine was mildly elevated from the reported 
baseline but was not overt failure. The member did not require any specific treatment and did not affect the 
overall course of the hospitalization. As such, the billing of N17.9 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 provided on November 19, 2021, through November 24, 2021, and billed with 
diagnosis code N17.9.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services billed with code 81599 for October 21, 2022. 
 
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 that the claim was not billed with the required Dex-Z identifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the claim was not billed with the required Dex-Z identifier; 
however, the referenced Local Coverage Determination (LCD) L36807 and Local Coverage Article (LCA) 
A57772 are not binding for the state of Colorado where the testing was performed. There is no binding 
Medicare rule stating that a Dex-Z identified is required for the state of Colorado. The Plan has not provided 
any documentation or binding Medicare rules to support that the services are not payable as billed. Therefore, 
we decided that the Plan has to pay for the laboratory services billed with code 81599 for October 21, 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.