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

 
We decided that the Plan does not have to pay for Medication assisted treatment, methadone andtake-home 
supply of methadone provided on February 13, 2023. 
 
You asked the Plan to pay for Medication assisted treatment, methadone andtake-home supply of methadone. 
You say that this service is supported in the records. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Medication assisted 
treatment, methadone andtake-home supply of methadone provided on February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug test (G0483) and presumptive drug test 
(80307) provided January 4, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that kindly find the attachment. Please review 
and reprocess your claim for payment. The Plan denied your request. The Plan says the services are not authorized because the individual listed as ordering the test is not a physician or qualified nonphysician 
practitioner who is treating the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the definitive drug test (G0483) and presumptive drug test (80307) provided January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 03, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that at the time of service the enrollee was 
residing in a nursing home. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 13, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on May 13, 2022.
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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for LTACH services.  the enrollee does not meet the Medicare criteria for LTACH 
services. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care.  
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 genetic testing provided on September 30, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this claim was not billed with the appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The sample for this testing was taken in an office setting; therefore, 
the POS code 81  indicating an independent laboratory setting  is not appropriate for this claim. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing provided on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided January 10, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Detect test for the enrollee. The Plan denied your request. The Plan says the Cxbladder test panel 
remains unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 15, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 15, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 You asked the Plan to pre-approve Darzalex Faspro. You say that this is medically necessary. The Plan denied 
your request. The Plan says the Plan requires a trial of Velcade before it will approve Darzalex Faspro. 
 
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 Darzalex Faspro. Our reviewer says 
that the enrollee does not meet criteria for a step therapy exception for Darzalex Faspro. Our physician 
reviewer found the enrollee has not tried and failed the Plan's preferred drug of Velcade. The record does not 
show that this drug would likely be less effective and/or 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 Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee had this treatment in the past and it 
worked. The Plan denied your request. The Plan says the clinical value and effectiveness of Botox in the setting 
of gastroparesis have not been demonstrated. 
 
The Plan follows Medicare rules. Medicare rules state that botulinum toxins such as Botox may be covered for 
label or certain off-label indications. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet criteria for Botox. Our physician reviewer found though trials evaluating the effect of 
intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement whether 
botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying study in 
patients with gastroparesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay the claim for inpatient services with diagnosis code J96.0. We decided that 
the Plan does not have to pay the claim for inpatient services with diagnosis code J15.6.  
 
You asked the Plan to pay for inpatient services. You say that the diagnosis codes are documented and 
clinically valid. You say that DRG 177 should be reinstated. The Plan says that diagnosis codes J15.6 and J96.0 
are not supported, which resulted in a DRG change. 
 
We decided that the Plan has to pay the claim for inpatient services with diagnosis code J96.0.  
 
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 more for the inpatient services. Our reviewer 
says that the documentation supports secondary diagnosis code J96.0. Our physician reviewer found the 
enrollee meets diagnosis code J96.0, as they had acute respiratory failure from pneumonia. Therefore, we 
decided that the Plan has to pay the claim for inpatient services with diagnosis code J96.0.  
 
We also decided that the Plan does not have to pay the claim for inpatient services with diagnosis code 
J15.6. 
 
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 more for the inpatient services. Our reviewer 
says that principal diagnosis code J15.6 is not supported. Our physician reviewer found that a gram-negative 
organism was not confirmed. Therefore, we decided that the Plan does not have to pay the claim for inpatient 
services with diagnosis code J15.6. 
 
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 physical therapy services provided on September 29, 2021, 
and October 6, 2021. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the 
provider rebilled the corrected claims with KX modifiers past the timely filing limit of 12 month. The claim 
denials are correct as there was ample time for provider to submit corrected claims after initial claims denial 
notice. 
 
 
 
 
 
 
 
 The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physical therapy services was not filed until February 10, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on  
September 29, 2021, and October 6, 2021.
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 the enrollee can continue weaning at 
LTACH and if unable to wean from the mechanical ventilation they can safely have a tracheotomy surgically 
placed at the LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and is currently unstable for transfer to an LTACH.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the medical records should be 
reviewed, and the claim considered for payment. The Plan denied your request. The Plan says this is a 
preventive service and is excluded from coverage under the DME benefit. 
  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ProGene pharmacogenomic testing provided on January 
11, 2023.  
 
You asked the Plan to pay for the ProGene pharmacogenomic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically 
necessary because the enrollee's records do not show that additional medications are being considered with 
known drug-gene interactions, that the enrollee is not responding to 
current medication, or that there are side effects or poor tolerance to current medications.  
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is medically reasonable 
and necessary when the criteria in the rules section of this letter 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 pay for the ProGene pharmacogenomic testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that no specific reports 
of issues with the medications were noted except for Norco not working anymore for leg/ankle/foot pain. 
Lyrica was restarted for this. The ProGene pharmacogenomic testing was provided on January 11, 2023. 
However, the enrollee doesn't meet LCD criteria for the ProGene test as the provided documentation doesn't 
clearly show that the enrollee is being considered for additional medications with known drug-gene 
interactions, that the enrollee is not responding to current medications, or that the enrollee is demonstrating side 
effects or poor tolerance to current medications. 
 
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 ProGene pharmacogenomic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the ProGene pharmacogenomic testing provided on January 11, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Puraply (Q4196) and application of skin substitute graft 
to lower leg (15721). 
 
You asked the Plan to pre-approve the wound care. You say that you have had a wound for over one year. You 
say that sometimes you have to go twice per week. You say that you cannot afford to keep paying $200 
copayments for this. You also say that you are worried this will get infected. The Plan denied your request. The 
Plan says the requested treatment 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 wound care. Our reviewer says that 
the requested wound care services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has a non-pressure, venous insufficiency ulcer 
of the lower extremity. The record provided does not establish that the enrollee has failed standard care or has 
an undermined complex ulcer. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the 
requested wound care services are not medically reasonable or 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 wound care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Puraply (Q4196) and application of skin substitute graft to lower leg (15721).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 5, 2023, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321-, 81351, 81209, 81314, 81334, 81345, 
and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought 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 
February 5, 2023, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321-, 81351, 
81209, 81314, 81334, 81345, and 81272.