Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found breast cancer-related lymphedema (BCRL) represents a significant concern for 
patients following breast cancer treatment, and assessment for BCRL represents a key component of 
survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. 
Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques 
such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for 
early intervention and low rates of chronic BCRL with level I evidence. The use of BIS has become a standard 
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 bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy.  
 
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 pre-approve a nuclear medicine thyroid scan (78013). 
 
You asked the Plan to pre-approve a nuclear medicine thyroid scan. You say that the records provided support 
the need for the services in dispute. The Plan denied your request. The Plan says there is no role for thyroid 
imaging in the work-up of hypothyroidism in adults. The Plan says that it does not help differentiate among 
causes, as all cases will have decreased radioiodine uptake, sometimes substantially. 
 
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 a nuclear medicine thyroid scan. Our 
reviewer says that a nuclear medicine thyroid scan is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of elevated thyroid-stimulating hormone (TSH) 
of greater than 5,000 and a history of thyroid goiter. A nuclear medicine thyroid scan was ordered on a routine wellness visit.  Thyroid uptake is another measure of thyroid function. Measurement allows for the diagnosing 
of hyperthyroidism, distinguishing other causes of thyrotoxicosis from hyperthyroidism, providing data for 
calculation of a therapeutic dose, and detecting intrathyroidal defects in organification. There is no role for 
thyroid imaging in the work-up of hypothyroidism in adults. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a nuclear medicine thyroid scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a nuclear medicine thyroid scan (78013).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have a history of failure, contraindication, or 
intolerance to oral bisphosphonate and an injectable bisphosphonate. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found The Plan requires a trial of drugs 
ibandronate, pamidronate, and zoledronic acid before they will approve the requested drug, Prolia. There is no 
indication that the enrollee has tried and failed the required drugs. There is no indication that the Plan's required 
drugs 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, hand; minimum of 3 views 
(73130-RT) provided on December 1, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service is supported as billed. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 x-ray. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The medical record documents: "Tests; Order Plain X-
ray/interpretation; The following images were ordered and obtained: BILATERAL UPPER: 3 Views, Hand; 
Weight-bearing: No; Right, Initial: Hand, 3+ views; 73130; INTERPRETATION(S)". In this case, the medical record does not include sufficient documentation to confirm procedure was performed, as documentation 
describes an order for radiology, but no interpretation was documented, and therefore, cannot be verified 
 
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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for the radiologic examination, hand; minimum of 3 views (73130-RT) provided on December 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy and Opdivo. 
 
You asked the Plan to pre-approve Yervoy and Opdivo. You say that these drugs are medically necessary. The 
Plan denied your request. The Plan says the requested drugs are not medically necessary for the patient's 
condition. 
 
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 Yervoy and Opdivo. Our reviewer says 
that Yervoy and Opdivo are not medically necessary. Our physician reviewer found these drugs are not FDA-
approved for the patient's diagnosis. There is no Phase III data to support the use of these drugs for the patient's condition and they remain investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and an electrocardiogram (ECG) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and an electrocardiogram (ECG). You say that you prefer to 
see a different provider because you are unhappy with your provider. The Plan denied your request. The 
Plan says this is available in-network. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and an electrocardiogram (ECG) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bio4 allograft (20930). 
 
You asked the Plan to pre-approve the Bio4 allograft. You say that the service is medically necessary. The Plan 
denied your request. The Plan says published studies do not demonstrate any long-term health outcome 
advantage with the use of Bio4 as an alternative to standard bony allografts. 
 
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 Bio4 allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the allograft is experimental in spine surgery. More research is needed. Iliac crest 
bone graft is the gold standard. 
 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 Bio4 allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Bio4 allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services. 
 
You asked the Plan to pre-approve PBRT. You say that the records provided support the need for PBRT. The 
Plan denied your request. The Plan says PBRT is not the standard of care for prostate cancer. 
 
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 PBRT. Our reviewer says that PBRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found PBRT would not 
be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member. The American Society for 
Radiation Oncology (ASTRO) and the National Comprehensive Cancer Network (NCCN) guidelines 
recommend against routine use of proton therapy. PBRT would exceed need for this patient. Any potential benefit or detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an 
investigational question. Whether proton therapy affords a benefit over other standard approaches for prostate 
cancer is an area of investigation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2021, to July 
23, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly. The Plan denied your request. The Plan says the records submitted do not support 
secondary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.01-Acute respiratory failure with hypoxia. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found the documentation does not consistently and completely 
support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis code and 
adjust the DRG is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 21, 2021, to July 23, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rental charge for a lightweight wheelchair billed with 
date of service December 27, 2022. 
 
You asked the Plan to pay for the monthly rental charge. You say that this should be paid as the chair was 
prescribed by your doctor. The Plan denied your request. The Plan says this was not billed correctly with the 
required modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that in addition to reporting modifier -RR, capped 
rental items should be billed with a modifier to indicate which month of the rental period is being billed.  
 We looked at the file and Medicare rules. The provider did not include a modifier -KH, -KI, or -KJ on this 
claim. Based on this information, we decided that Medicare rules for coverage of the monthly rental charge 
have not been met. Therefore, we decided that the Plan does not have to pay for the rental charge for a 
lightweight wheelchair billed with date of service December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on May 11, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
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 initial hospital care. Our reviewer found the documented 
physical findings was broad, but not comprehensive. The enrollee was stable without evidence of severe or 
complex disease. There was insufficient support made in the provided documentation that this note described a 
comprehensive history or physical, nor was there evidence of medical decision-making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital care (99223) provided on May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 16, 2018, to 
June 19, 2018, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly. The Plan denied your request. The Plan says the principal diagnosis code A41.9, is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9- Sepsis, unspecified organism. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our physician reviewer found the enrollee was hospitalized with colitis. The enrollee was ruled out for C. 
difficile. The enrollee is noted to have remained stable throughout the enrollee's stay. There is no evidence of 
systemic illness or organ failure. As such, the diagnosis of A41.9 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 16, 2018, to June 19, 2018, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the patient has new clinical signs, so this test is 
medically necessary. The Plan denied your request. The Plan says this test is being used as a screening since 
the patient has no signs or symptoms of cardiac disease. 
 
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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient is a 72-year-old female who was seen at an outpatient visit on 3/31/23 for regular 
check up to discuss her conditions (diabetes, obesity, osteoporosis, chronic kidney disease, hyperlipidemia, 
hypertension, and joint pain.) It was reported that she was "currently asymptomatic" and no new symptoms were reported. Heart exam revealed mid-systolic murmur of 2/6 grade soft quality. Transthoracic 
echocardiogram (TTE) was requested as a follow-up evaluation. However, the provided documentation did not 
explain if the murmur was new or not, but suggested it was not as it appeared to be a routine test. Routine TTE 
is not standard of care without new symptoms or findings on examination. The documentation did not show 
sufficient evidence that these requirements were met to justify this test for follow-up. Therefore, the TTE will 
be considered not 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 a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (53854). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the ReZum procedure is considered experimental and/or contraindicated in men with prostate 
cancer. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transurethral destruction of prostate tissue; by radiofrequency generated water vapor 
thermotherapy (53854).