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

 
We decided that the Plan does not have to pre-approve Aranesp and Epotein alfa-epbx. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has beta thalassemia minor 
and anemia of chronic kidney disease. Iron studies on June 13, 2022 showed a ferritin of 113 and an iron 
saturation of 41 percent. On August 13, 2023 her hemoglobin was 8.8 The combination of Aranesp and Epotein 
alfa-epbx is not approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The use is 
not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. The combination is not reasonable and medically necessary or safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp and Epotein alfa-epbx.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for March 15, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 83520 and 87798 are not supported. 
 
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 83520 is  
immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not 
otherwise specified. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified; amplified probe technique, each organism. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that procedure codes 83520 
and 87798 are not supported. Our reviewer found there is no documentation or laboratory orders to support that 
codes 83520 and 87798 were performed for the billed date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 83520 and 87798 billed for March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physician's services to be provided by an out-of-network provider. You say 
that your dermatologist has recommended that you see a specialist in Denver for your alopecia. The Plan 
denied your request. The Plan says must receive her care from network providers. One exception to this rule 
would be if you need medical care that Medicare requires our Plan to cover and the providers in our network 
cannot provide this care, you could get this care from an out-of-network provider if we authorize the services 
before you get the care. The Health Plans reviewing physician stated that treatment for alopecia is a non-
emergent condition and does not require emergency surgical services. The clinical expertise to evaluate 
and treat alopecia is available in-network or at a contracted location with a contracted provider. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need to replace your current 
compression stockings. The Plan denied your request. The Plan says these compressions stockings have been 
correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay the billed amount for the inpatient hospital services provided from 
November 24, 2022, through December 16, 2022.  
 
You asked the Plan to pay the billed amount for the inpatient care. You say that this was billed correctly.  The 
Plan denied your request. The Plan says that there are charged from the itemized bill that are not considered 
separate and are not supported for payment.  
 
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. in this case, the Plan has indicated that there are remaining charges that are not 
supported in the record. However, the file did not include an itemized bill summary which listed the line items 
which remained denied by the Plan. Without evidence showing the charges in dispute, a determination 
regarding their appropriateness cannot be made.  Therefore, we decided that the Plan has to pay the billed 
amount for the inpatient hospital services provided from November 24, 2022, through December 16, 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 code 99232 billed for dates of service May 16, 2023, and 
May 17, 2023. 
 
You asked the Plan to pay for code 99232. You say that this denial is erroneous. The Plan denied your request. 
The Plan says code 99232 is not supported by the medical record. The medical records submitted don't support 
moderate level of medical decision making or total time required of the code 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 code 99232 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
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 code 99232. Our reviewer says that code 99232 is not 
supported by the dates of service billed. Our reviewer found the medical records support a moderate 
complexity of problems; a limited amount of complexity data reviewed and analyzed; and a low risk of 
complications and/or morbidity or mortality of patient management.  In this case, code 99231 is the correct 
code based on the documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99232 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99232 billed for dates of service May 16, 2023, and May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided from March 11, 2023, to  
April 15, 2023.  
 
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. 
 
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 decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the podiatry services have been met.  
Therefore, we decided that the Plan does not have to pay for podiatry services provided from March 11, 2023, 
to April 15, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vectibix (J9303), Carboplatin (J9045), and Paclitaxel (J9267). 
 
You asked the Plan to pre-approve Vectibix, Carboplatin, and Paclitaxel. You say that the services are 
necessary. The Plan denied your request. The Plan says that 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 Vectibix, Carboplatin, and Paclitaxel. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the use of the 
requested drugs are supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. There is evidence that epidermal growth factor receptor (EGFR) E114K 
mutation may be more sensitive to cetuximab and panitumumab used on colorectal EGFR studies. The 
combination regimen has been used in studies and demonstrated to be safe and effective. Given progression of 
disease on multiple other regimens, the currently recommended regimen is reasonable and necessary at this 
point 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 Vectibix, Carboplatin, and Paclitaxel have been met. Therefore, we decided that 
the Plan has to pre-approve Vectibix (J9303), Carboplatin (J9045), and Paclitaxel (J9267).  
 
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 reimburse you for assisted living room and board provided from 
January 16, 2023, to March 31, 2023. 
 
You asked the Plan to reimburse you for assisted living room and board. You say that you were at this facility 
due to a fall that resulted in breaking both of your legs in December 2022. You say that you made many phone 
calls to other facilities and either they did not have a vacancy or a Hoyer lift. The Plan denied your request. The 
Plan says that the services were obtained from a facility that is not under contract with the Plan and is not 
certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that you received services from a provider that is not 
enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
assisted living room and board provided from January 16, 2023, to March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2023, billed with 
multiple individual codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary.  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 4, 2023, billed with multiple individual codes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health treatment from October 3, 
2023-forward. 
 
You asked the Plan to pre-approve inpatient behavioral health treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided this enrollee does not meet the criteria for October 3, 2023 forward as this 
enrollee was not shown to be a danger to herself or others. No delusions, auditory or visual hallucinations were 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
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 behavioral health treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health treatment from October 3, 2023-forward.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for surgical dental services (21248, 21089, 21248, 21210, 15574, 21210, 
41899, 70486, 70355, 99211, 70300) provided on July 25 and July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says that the services denied correctly as they 
do not meet the clinical requirements to be approved. 
 
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 did not send a comprehensive operative report and all dental records for 
both dates of service in dispute. The record includes notes from the provider, but only address the July 25, 2022 
date of service and not the July 26, 2022 date of service. In-network providers are considered agents of the Plan 
and the limited records provided do not suffice. Therefore, we decided that the Plan has to pay for surgical 
dental services (21248, 21089, 21248, 21210, 15574, 21210, 41899, 70486, 70355, 99211, 70300) provided on 
July 25, 2022 and July 26, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips (A4253). 
 
You asked the Plan to pre-approve OneTouch Ultra test strips. You say that the items are necessary. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands.  The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered 
under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for OneTouch Ultra test strips. Therefore, we decided that the Plan does not have to pre-approve OneTouch 
Ultra test strips (A4253).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641 and 87500 billed for April 19, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are not 
supported. 
 
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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for these 
services. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 
87640, 87653, 87798, 87641 and 87500 billed for April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that LAAC 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 not medically necessary. Our physician reviewer found the enrollee has a history of atrial 
fibrillation. He has a congestive heart failure, hypertension, age =75 (doubled), diabetes, stroke (doubled), 
vascular disease, age 65 to 74 and sex category (CHADS2VASC) score of two. There is no contraindication to 
anticoagulation, according to the physician. The criteria for coverage of LAAC are not met and the services are 
not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve left atrial appendage closure (LAAC).