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

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Reblozyl is not 
medically necessary.  
 
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 the drug. Our reviewer says that 
Reblozyl is not medically necessary.  Our physician reviewer found Reblozyl is not supported by one of the 
major drug compendia or by clinical research. The enrollee should receive a hypomethylating agents instead of 
luspatercept.  
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve the medication. You say that Dupixent is medically necessary and is the 
most appropriate course of treatment to manage the enrollee's condition effectively. 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 Dupixent.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute. 
 
You asked the Plan to pre-approve skin substitute. 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. 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 skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided medical records and review of the current peer-reviewed medical literature do not 
document that use of a skin substitute has been shown in controlled studies in a Medicare-approved journal to 
result in long term health benefits in patients in patients undergoing Mohs micrographic surgery (MMS). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 24, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device. 
 
You asked the Plan to pre-approve Barostim Neo. You say that the enrollee is an excellent candidate for this 
treatment. The Plan denied your request. The Plan says the Barostim Neo procedure has not been shown to be 
safe and effective. 
 
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 Barostim Neo. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term 
outcomes to establish the value of Barostim Neo in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat mechanism, side rails, and transfer bench. 
 
You asked the Plan to pre-approve a seat mechanism, side rails, and transfer bench. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for durable medical equipment that 
is mainly used to serve a medical purpose. 
 
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 seat mechanism, side rails, and 
transfer bench. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
the enrollee must be able to walk. The enrollee has MS and is non ambulatory. 
 
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 seat mechanism, side rails, and transfer bench have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a seat mechanism, side rails, and transfer bench.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 11, 2021, 
to November 15, 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  
diagnosis J18.9 is supported in the record, therefore the claim should be paid at the original DRG. The Plan 
denied your request. The Plan says J18.9 is not supported in the record. 
 
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 secondary diagnosis J18.9, defined as pneumonia, 
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 reviewer says that secondary diagnosis code J18.9 is not supported in 
the documentation. Our physician reviewer found the computed topography (CT) scan report in the record is 
detailed in reporting pulmonary findings consistent with metastatic lung cancer but no findings to suggest 
pneumonia. Microbiology studies were negative. The enrollee was previously diagnosed with post-obstructive 
pneumonia 2 weeks prior and was treated with antibiotics, though no sputum culture was obtained.  
 
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 November 11, 2021, to November 15, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (99232) provided on February 28, 2023. 
 
You asked the Plan to pay for the hospital services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, diagnosis code F05 is not a 
valid primary diagnosis code. The underlying condition must be coded first. Based on this information, we 
decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that 
the Plan does not have to pay for hospital services (99232) provided on February 28, 2023.
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 February 20, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should 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 
February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on September 12, 2022, billed 
with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on September 12, 2022, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87640, 87651, 87798 and U0005.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 1, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc (0627T). 
 
You asked the Plan to pre-approve the procedure. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the requested procedure does not meet the requirements for approval. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/ investigational procedure. Therefore, the procedure is not medically 
reasonable and 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral 
disc (0627T).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Bio-Genetics CGX Comprehensive Complete Cancer Panel (82 genes) 
provided on April 5, 2023. 
 
You asked the Plan to pay for the comprehensive cancer panel. You say that this test was medically necessary 
and was billed appropriately. The Plan denied your request. The Plan says that this panel does not meet FDA 
approval or have clearance as a companion in vitro diagnostic or an FDA-approved or -cleared indication. 
 
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 pay for the comprehensive cancer panel. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a personal history of breast cancer along with family history of 
breast and endometrial cancer. Therefore, it is reasonable for her to undergo genetic testing. 
 
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 comprehensive cancer panel have been met. Therefore, we decided that the 
Plan has to pay for Bio-Genetics CGX Comprehensive Complete Cancer Panel (82 genes) provided on April 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve the therapy services. You say that you are in pain. The Plan denied your 
request. The Plan says aquatic therapy is not medically necessary, and the provider is out-of-network. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
there is no documentation of a recent injury or decline in function. Additionally, the documentation does not 
support that you require aquatic therapy and there is no reason clearly documented that you cannot participate 
in a land-based home-exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic therapy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 additional units of EpiFix membrane allograft. 
 
You asked the Plan to pre-approve EpiFix. You say that the enrollee has had this wound on and off for over a 
year, that the wound is responding well to the treatments, and that continuing to treat it will help prevent future 
reopening. The Plan denied your request. The Plan says that that the enrollee has reached the allowed number 
of EpiFix applications. 
 
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 EpiFix. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the medical documentation supports that this enrollee is suffering with a right lower 
extremity wound which was initially nonhealing. Applications of EpiFix wound covering has allowed for 
healing of the ulceration. In this case, the enrollee has undergone wound debridement and offloading but 
continues to exhibit a right lower extremity ulceration. EpiFix wound dressing has demonstrated efficacy in 
healing recalcitrant chronic stalled wounds including diabetic wounds, burns, and venous stasis wounds. It 
appears reasonable within the guidelines mentioned above for additional EpiFix applications for this enrollees 
wound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EpiFix have been met. Therefore, we decided that the Plan has to pre-approve 5 
additional units of EpiFix membrane allograft.  
 
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 outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided on March 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. 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 the outpatient intravenous (IV) insulin therapy (OIVIT) services provided on March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service April 
18, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code procedure code 83520 is immunoassay for analyte other 
than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
The CPT Code Manual definition of code procedure code 87798 is infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
 
 We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, the order lab 
requisition must include what laboratory test was ordered/requested in order to validate the not otherwise 
specified code billed. Therefore, code 83520 cannot be verified. The documentation shows that there is a more 
appropriate lab panel code that should be used to bill when one or more CPT codes are included in the same 
panel; therefore, code 87798 cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of codes 83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 83520 and 87798 for date of service April 18, 2023.