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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should be included in the dialysis rate. 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 related to end-stage renal disease (ESRD) provided on 
December 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 3, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 3, 2022, to 
October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0402 and G0463 billed for date of service 
December 7, 2022. 
 
You asked the Plan to pay for procedure codes G0402 and G0463. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0402 and G0463 are not supported in the medical record. Specifically, a review of 
the file shows that the claim was not billed with condition code G0. Billing multiple medical visits in the same 
day requires this condition code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes G0402 and G0463 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes G0402 and G0463 billed for date of service December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies billed with codes A6223, A6220, 
A6446, A4450, and A6196 for February 15, 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 the services are not covered in a SNF. 
 
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 these services were used in a SNF. Therefore, we decided that the Plan does not have to pay 
for the wound care supplies billed with codes A6223, A6220, A6446, A4450, and A6196 for February 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home non-invasive ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show a failure of bilevel positive airway pressure (BiPAP). 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that there are no pulmonary function tests to confirm obstructive lung disease or assess severity. A compliance report 
covering January 19 to February 6, 2023 shows the device was used at least 4 hours/day for 68% in of days. 
The minimum Medicare requirement is 70% of days. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home non-invasive ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Neulasta is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of high-grade 
adenocarcinoma of the urethra with inguinal adenopathy, bone metastasis, and metastatic lesions. The New 
Patient Consult dated December 21, 2022 documents that prioritizing systemic therapy indication for adjuvant 
chemotherapy. The enrollee is aged greater than 65 years and has uncontrolled primary disease. The criteria for 
coverage are met and the Neulasta is reasonable and medically necessary at this time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Neulasta.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 You asked the Plan to pre-approve Actemra. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the step therapy requirements have not been 
met.  
 
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 Actemra. Our reviewer says that 
Actemra is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Remicade, Inflectra, infliximab, or Simponi Aria. There is no documentation indicating that the 
Plan's required drugs would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM system. 
 
You asked the Plan to pre-approve a CGM system. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a CGM system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre CGM system.
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-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to and from 
medical appointments. 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 one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. In this case the requested transportation 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-mile limit.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the enrollee has an iron deficiency and needs 
Injectafer. The Plan denied your request. The Plan says the step therapy requirements have not been met.  
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Infed or Venofer. There is no documentation provided indicating that the Plan's required drugs 
would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services will provide the enrollee the intense 
therapy needed for their recovery and return to their prior level of function.  The Plan denied your request. The 
Plan says admission to the IRF 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 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 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. There 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mastopexy and insertion of implant. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has had weight loss following bariatric surgery.   The 
record does not indicate that the requested service is required to repair abnormal structures of the body caused 
by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. The record provided 
does not establish the presence of functional impairment. The elements of the coverage criteria are not 
satisfied. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve mastopexy and insertion of implant.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroplasty.  
 
You asked the Plan to pre-approve a sacroplasty. You say that a sacroplasty is medically necessary. The Plan 
denied your request. The Plan says that a sacroplasty 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 a sacroplasty. Our reviewer says that 
the requested sacroplasty is considered medically reasonable and necessary in this case. Our physician reviewer 
found that this enrollee was being treated for pathological fracture of other sites (bilateral sacral insufficiency 
fracture). The enrollee presented with pain in the bilateral sacrum that started about two months ago. The pain 
is sharp at times and averages 6-9/10. The exam reveals decreased bilateral lower extremity strength at 4/5. The 
enrollees computerized tomography (CT) scan of the pelvis has impressions of unchanged subacute mildly 
displaced U-type sacral insufficiency fracture with a transverse fracture plane through the S1 level. The 
enrollee has not improved and notes a failure of the fractures to heal on their own. The enrollee has a history of 
malignant neoplasm of the upper lobe of right lung; malignant neoplasm metastatic to right adrenal gland. Peer-
reviewed literature support the requested procedure as a safe and effective treatment option. Therefore, the 
requested sacroplasty, in this case, is 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 a sacroplasty have been met. Therefore, we decided that the Plan has to pre-
approve a sacroplasty.   
 
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 pay for inpatient hospital services billed with diagnosis code G92 
rendered from June 24, 2021, to June 27, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment Clinical 
Validation Audit was performed to ensure that the diagnosis codes on the claim supported clinically, and the 
DRG was updated. 
 
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 diagnosis code G92 - toxic encephalopathy. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the enrollee was diagnosed with polypharmacy. Mental status 
improved after medication adjustments. There is a more specific diagnosis for this clinical scenario, T50.995A 
(adverse effects of drugs) that would be more appropriate for this admission. There was insufficient support 
made for the code, G92 (toxic encephalopathy). Therefore, the more appropriate DRG is 948 for this 
admission.  
 
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 billed with diagnosis code G92 rendered from June 24, 2021, to June 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 19, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81306, 81328, 81355 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
September 19, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 81306, 81328, 81355 and 81238.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. 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 related to end-stage renal disease (ESRD) provided on 
December 12, 2022.