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

 
We decided that the Plan does not have to pre-approve the Prolia (denosumab) (J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says there is no indication the enrollee has had an osteoporosis-related fracture. The Plan states the enrollee has not tried and failed zoledronic acid and there is 
no indication zoledronic acid, an intravenous (IV) bisphosphonate drug, would likely be: less effective, and/or 
cause adverse effects for the enrollee. 
 
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 the medication. Our physician reviewer 
found the Plan requires one of the following to be met: either a history of osteoporosis-related fracture; OR, the 
enrollee has failed or has a contraindication to zoledronic acid (the Plan's preferred step therapy drug) before 
the Plan will approve the requested drug. There is no indication the enrollee has had an osteoporosis-related 
fracture. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation 
provided indicating that the Plans required drug(s) would likely be less effective and/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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Prolia (denosumab) (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided February 22, 
2023. 
 
You asked the Plan to pay for the orthosis. You say that please find the attached documents which proves 
medical necessity of this enrollee and process the claim towards payment. The Plan denied your request. The 
Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis (L0650) provided February 22, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 93970. We decided that the Plan does not have to pay for 76856 and 
76881.  
 
You asked the Plan to pay for procedure codes 76856, 76881 and 93970 rendered on December 12, 2022.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for CPT 93970.  
 
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 CPT 93970 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study." 
 
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 for CPT 93970. Our reviewer says that a bilateral 
lower extremity ultrasound was done and documented on December 12, 2022. 
 
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 
93970.  
 
We also decided that the Plan does not have to pay for CPT 76856 and CPT 76881. 
 
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 remaining codes is: 
 
CPT 76856: 
 
Ultrasound, pelvic (nonobstetric), real time with image documentation; complete 
 
CPT 76881: 
 
Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image 
documentation 
 
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 for these codes. Our reviewer says that CPT 76856 is a 
complete pelvic ultrasound. The exam done was a prostate ultrasound with post-void residual volume. This 
exam should have been coded as CPT 76857. 
 
In terms of CPT 76881, this is a joint space evaluation and surrounding tissues. This is included as part of the 
bilateral lower extremity venous ultrasound - CPT 93970. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 76856 and 76881 have not been met. Therefore, we decided that the Plan does 
not have to pay for 76856 and 76881. 
 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for debridement, muscle and/or fascia (includes epidermis, dermis, and 
subcutaneous tissue, if performed); first 20 sq cm or less rendered on August 31, 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 that 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 
code 11043 is "Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if 
performed); first 20 sq cm or less." 
 
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 supported by the medical records. Our reviewer found that the records do reasonably support 
CPT 11043 as a separate and distinct procedure from CPT 26034. The procedure details cite the nail plate was 
removed. A bur was then used to open the radial cortex of the distal phalanx. The intramedullary space of the 
distal phalanx was explored. There was a small amount of edema/clear fluid. No purulence or abscess was 
seen. Samples of the bone of the distal phalanx were then obtained using a curette and sent to pathology. An 
excisional debridement of the bone of the distal phalanx was then performed using elevators/curettes. This 
excisional debridement of the bone of the distal phalanx was a procedure separate from and of a greater 
magnitude than a basic procedure bone opening incision. This is despite the denoted lack of purulence/abscess. 
The documentation does reasonably support that it was a separate and distinct procedure. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 
sq cm or less rendered on August 31, 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: 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 January 19, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not 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 January 
19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87636) provided on February 1, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab testing have 
not been met. Therefore, we decided that the Plan does not have to pay for lab testing (87636) provided on 
February 1, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for sepsis and cellulitis. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 9, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee prosthesis and components. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support that the enrollee is a K3 ambulator. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the physician documentation does not support that the enrollee's functional level is a K3. There is no 
requirement for a K3 foot. The enrollee uses a walker and wheelchair. The documentation from the physician 
does not support a need for a new socket. The requested items exceed the enrollee's medical and functional needs and are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a below knee prosthesis and components.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Respiratory polymerase chain reaction (PCR) Panel provided 
on May 18, 2022, billed with codes 87486-59, 87496-59, 87498-59, 87502-59, 87532-59, 87541-59, 87581-59, 
87634-59, 87640-59, 87798-91x6, U0003, and U0005. 
 
You asked the Plan to pay for the laboratory testing billed. You say that this should be considered a covered 
service as the diagnosis provided to order the test was not for preventative care and was in fact 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 laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for Respiratory polymerase 
chain reaction (PCR) Panel provided on May 18, 2022, billed with codes 87486-59, 87496-59, 87498-59, 
87502-59, 87532-59, 87541-59, 87581-59, 87634-59, 87640-59, 87798-91x6, U0003, and U0005.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM would help the enrollee. The Plan denied your 
request. The Plan says that the medical criteria for a CGM have not been met. 
 
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 has failed to provide medical records for the enrollee. Therefore, we 
decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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 Lumigan solution. 
 
You asked the Plan to pre-approve Lumigan solution. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan solution.   
Benefits for Lumigan solution may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the oxygen concentrator (E1390) and portable gaseous oxygen system 
(E0431) provided January 5, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you are being billed for January and you do 
not feel that you owe this amount because you only used the equipment in December, and it was picked up in 
January. The Plan denied your request. The Plan says that Medicare does not prorate charges for services. 
 
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. There were no medical records provided. There was no information provided 
indicting the date that the oxygen equipment was returned. The Plan has not substantiated their reason to 
continue to deny. Therefore, we decided that the Plan has to pay for the oxygen concentrator (E1390) and 
portable gaseous oxygen system (E0431) provided January 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
November 2, 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that this was correctly billed. The Plan denied 
your request. The Plan says the enrollee's symptoms did not require highly complex decision making.  
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 ED services as billed. Our reviewer says 
that the billed code is not supported by the records.  Our reviewer found the enrollee was seen in the ED for an 
upper respiratory infection with sore throat. In this case, the medical records submitted do not support medical 
decision making of high complexity.   
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on November 2, 2022, billed with 
code 99285.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from October 3, 2022, to 
October 7, 2022 
 
You asked the Plan to pay for the inpatient hospital care. The Plan denied your request. The Plan says that 
claims were found for the same provider and same dates of service. 
 
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. Specifically, the Plan has not provided a rule to substantiate their denial. The 
Plan has not proof of the claims that were paid to support the denial that these claims are duplicates. Therefore, 
we decided that the Plan has to pay for inpatient hospital care provided from October 3, 2022, to 
October 7, 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.