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

 
We decided that the Plan does not have to pay for assistant surgeon services rendered on January 30, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not clearly document the assistant surgeon's role during the operative 
session. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 61885. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
based on the medical records provided there is no documentation that the assistant surgeon services rendered 
on January 30, 2023, at issue in this case meet all Medicare criteria for medically reasonable and necessary for 
the enrollee. The provided records in this case do not document necessity of the assistant surgeon or what 
specific role or duties the assistant surgeon provided in this case. Assistant at surgery services will not be paid 
unless supporting documentation is submitted to establish medical necessity. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for assistant surgeon services rendered on January 30, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for an epoetin alfa-epbx injection rendered on September 6, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that services that are considered experimental or investigational are excluded from 
coverage. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that in 
this case, the record indicates that the enrollee has a diagnosis of chronic anemia and has required transfusion 
in the setting of chronic renal disease. The Food and Drug Administration has stated that the requested drug is 
indicated for the enrollee's condition. The elements of the coverage criteria are 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 services have been met. Therefore, we decided that the Plan has to pay for 
an epoetin alfa-epbx injection rendered on September 6, 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 Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the clinical documentation provided supports the 
need for the drug in dispute.  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 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 Fulphila. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use for Fulphila is not 
FDA-approved for the enrollee's diagnosis. Fulphila is indicated in patients with non-myeloid malignancies 
receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile 
neutropenia. There is a warning for use in patient with Acute Myelogenous Leukemia (AML) as it can lead to myelodysplastic syndrome. The use of this drug is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-approved medical journal.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on May 4, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that this medical claim for physical 
therapy was a referral from a dentist for the diagnosis of TMJ. You say that you called and spoke to a 
representative who said that the enrollee's contract allowed for coverage. You say that the services provided 
were medically necessary and are supported by the documentation provided. The Plan denied your request. The 
Plan says the enrollee's contract does not cover charges for treatment of TMJ other than by an open-cutting 
operation. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary. Medicare rules also say that the patient's medical record should include certain elements in order to 
support medical necessity.  
 
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 physical therapy services. Our reviewer 
says that the criteria for coverage have not been met.  Our physician reviewer found the documentation 
available for review did not include a description of previous treatment such as patient education, the use of 
medications, or the use of bite splints.  There was not a relevant medical history or pertinent tests/procedures 
from the referring medical provider. There is no indication the enrollee failed initial conservative treatment that 
would require referral for skilled outpatient rehabilitation.  Additionally, the enrollee had previously been 
treated with outpatient therapies (starting in April 2022) and should have received adequate education and 
treatment to allow for home care. The requested therapy services were not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0315U) rendered on 
March 21, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the services were deemed 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that DecisionDx-SCC is a genomic test that was developed to predict metastatic risk for SCC patients 
with one or more risk factors. High-risk features are depth of invasion (more than 2 mm), poor histological 
differentiation, high-risk anatomic location (face, ear, pre/post auricular, genitalia, hands, and feet), perineural 
involvement, recurrence, multiple cSCC tumors, and immunosuppression. None of these are documented in 
this 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 0315U) rendered on March 21, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided on January 17, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that you were diagnosed with 
temporomandibular joint dysfunction (TMJ) disorder and were referred to physical therapy to help reduce the 
pain. The Plan denied your request. The Plan says that the services are non-covered because they involve the 
care, treatment, filling, removal or replacement of teeth or structure directly supporting the teeth.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the physical therapy services by a contract provider. Treatment of TMJ could be covered 
under some conditions, so the EOC alone is not adequate notice of non-coverage. The file does not show that 
the Plan provided notice that the physical therapy services would not be covered. Under Medicare rules, this 
means the physical therapy services is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for physical therapy services provided on January 17, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 1, 
2023, to January 15, 2023. 
 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 there were no daily skilled services needed. 
 
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 based on the documentation provided, the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services are not shown to have been required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
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 January 1, 2023, to January 15, 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 should be receiving the same benefits as 
Medicare. The Plan denied your request. The Plan says you do not meet the requirements for inpatient 
rehabilitation. Services needed may be provided safely in a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lumbar spine surgery. Your medical problems are stable. There are no complex nursing or rehabilitation needs.  
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports 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. There is not a reasonable expectation that you 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 IRF admission and services.
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 inpatient rehabilitation will improve the enrollee's 
mobility, activities of daily living, and gait.  The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval. Services needed may be provided safely in a lower level of care.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including either physical therapy 
and occupational therapy, and is anticipated to require at least 3 hours per day for 5 days a week. There is 
documentation that there is a reasonable expectation that this 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the enrollee does meet all the requirements. Services 
needed may be provided safely in a lower level of care.  
 
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 the enrollee is receiving appropriate care in current acute care setting. The 
documentation does not support that LTACH services are medically appropriate at this time. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87641, and 87798 rendered on 
September 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 87150: 
 
Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or 
isolate, each organism probed 
 
CPT 87641: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique 
 
CPT 87798: 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 87150 is not supported 
as a separate and distinct procedure. The records show that the tests reported with 87150 were included in 
87500 and cannot be reported separately. 
 
CPT code 87798 is not supported as a separate and distinct procedure. The multiple organisms tested and 
reported with 87801 include the not otherwise specified organisms reported with 87798. 
 
CPT code 87641 is not supported. The record does not contain evidence supporting that infectious agent 
detection of MRSA was performed. The record states that stapholococcus aureus was not tested for in this 
sample. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87150, 87641, and 87798 rendered on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PGx markers panel genetic testing. 
 You asked the Plan to pre-approve the testing. You say that this is needed for drug metabolism effectiveness. 
The Plan denied your request. The Plan says the initial denial was appropriate given the available clinical 
documentation. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a pre-service request for PGx markers panel genetic testing was made for drug metabolism 
effectiveness. However, this panel includes genes that would not be related to changes in the enrollee's 
treatment plan including medications. Therefore, the criteria are not met for coverage.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PGx markers panel genetic testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the claim was not received timely. 
 
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 pre-approve 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 Based on the limited documentation provided, the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs.  Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of the enrollees condition. 
 
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 pre-approve skilled nursing facility (SNF) care.