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

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service November 5, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this claim was submitted with 
two incompatible diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition together with the condition with the note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 86077 have not been met. Specifically, this claim was submitted with diagnosis 
codes R02.06 (shortness of breath) and J96.2 (acute on chronic respiratory failure). However, codes within the 
R06 code set have an Excludes1 note with codes within the J96 code set. This means that it is generally 
inappropriate to bill these codes together. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service November 5, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a virtual colonoscopy screening, including image postprocessing. 
 
You asked the Plan to pay for the virtual colonoscopy screening, including image postprocessing. You say that 
the virtual colonoscopy screening, including image postprocessing was medically necessary. The Plan denied 
your request. The Plan says that the virtual colonoscopy screening, including image postprocessing is not 
covered per the Medicare Local Coverage Article: A56772.  
 
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 virtual colonoscopy screening, including 
image postprocessing. Our reviewer says that the requested virtual colonoscopy screening, including image 
postprocessing is considered medically reasonable and necessary in this case. Our physician reviewer found 
that CT Colonography is a recognized modality for colorectal cancer screening endorsed by national clinical 
guidelines as safe, effective, and not experimental. 
 
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 virtual colonoscopy screening, including image postprocessing have been 
met. Therefore, we decided that the Plan has to pay for the virtual colonoscopy screening, including image 
postprocessing.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service February 6, 
2023, to March 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the reconsideration 
request. The Plan denied your request. The Plan says the documentation does not support the billed diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that the home health care was billed with primary diagnosis code S81.832D, puncture wound without 
foreign body, left lower leg, subsequent encounter. The records provided show that skilled nursing was ordered 
for wound complications from a pressure ulcer. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health care billed for dates of service February 6, 2023, to March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on November 2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0117U is non-covered for 
pharmacogenomic testing.  
 
We looked at the file and Medicare rules. Per A58801, the billed code, 0117U, is not covered for 
pharmacogenomic testing. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided on 
November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full cast high noble metal crown (D2790). 
 
You asked the Plan to pre-approve a full cast high noble metal crown. You say that the service is necessary. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a full 
cast high noble metal crown (D2790).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4239 billed for date of service March 17, 2023. 
 
You asked the Plan to pay for code A4239. The Plan denied your request. The Plan says code A4239 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that code A4239 has a status indicator of P on the Physician Fee Schedule. This means that code 
A4239 is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
code A4239 have not been met. Therefore, we decided that the Plan does not have to pay for code A4239 billed 
for date of service March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
low back pain due to lumbar spondylosis. He had bilateral lumbar medial branch blocks. There is no 
documentation of a physician-directed physical therapy program for this pain for a minimum of three months. 
The criteria for coverage are not met and the RFA is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 24, 2023. 
 
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 
January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on November 22, 2022. 
 
You asked the Plan to pay for the testing. 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 testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on November 22, 
2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided February 1, 2021, to February 22, 
2021. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that payment of final bill based on total episode of care minus any 
payments made on prior RAP claims. 
 
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. Review of the file shows that the Plan states that payment of final bill based on 
total episode of care minus any payments made on prior RAP claims. The documentation did not include an 
explanation on the payments made on prior RAP claims. No explanation was provided on why these services 
have been denied or what Medicare rules were used to support this denial. No other denial rationale was 
provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
home health services provided February 1, 2021, to February 22, 2021.  
 
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 treatment with carboplatin (J9045), etoposide (J9181) 
and pembrolizumab (J9271). 
 
You asked the Plan to pre-approve carboplatin, etoposide and pembrolizumab. You say that the requested drugs 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested anticancer 
regimen has been prescribed for an off-label, not medically accepted use. 
 
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 carboplatin, etoposide and 
pembrolizumab. Our reviewer says that treatment with carboplatin, etoposide and pembrolizumab is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of 
carboplatin, etoposide and pembrolizumab is not FDA-approved for the enrollees diagnosis. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carboplatin, etoposide and pembrolizumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve treatment with carboplatin (J9045), etoposide (J9181) and 
pembrolizumab (J9271).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that this is the appropriate therapy for the enrollee due to 
their medical history. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Forteo. 
 
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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Forteo. The reviewer found that 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. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried conservative 
treatment without relief. You also say that this is medically necessary for the enrollee. The Plan denied your 
request. The Plan says this procedure is considered medically reasonable and necessary when the beneficiary 
has had two positive sequential facet joint injections/medial branch blocks, using a local anesthetic, with 80% 
relief of the facet mediated pain. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. Current medical literature indicates that the Intracept procedure is 
investigational at this time. Therefore, the reviewer found that the requested Intracept procedure is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
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 the enrollee needs rehabilitation and the hospital 
does not have the resources to help the enrollee. The Plan denied your request. The Plan says the enrollee does 
not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the records provided support that Dupixent has 
given excellent response and lack of side effects.  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 Dupixent 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: 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 admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to a LTACH does not meet criteria. 
 
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 was admitted with weakness. The record indicates that the enrollee is 
improving but still requires acute care services before transitioning to a lower level of care. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPECT myocardial perfusion imaging. 
 
You asked the Plan to pre-approve SPECT myocardial perfusion imaging. You say that SPECT myocardial 
perfusion imaging is medically necessary. The Plan denied your request. The Plan says SPECT myocardial 
perfusion imaging does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 SPECT myocardial perfusion imaging. 
Our reviewer says that the requested SPECT myocardial perfusion imaging is not considered medically 
necessary in this case. Our physician reviewer found that there is no documentation that the ECG shows an 
uninterpretable pattern or that the enrollee is unable to exercise. There is no evidence provided that would 
support the need for radionuclide stress testing at this time. There is insufficient documentation to support the 
medical necessity for the requested cardiac stress testing in this enrollees clinical 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 SPECT myocardial perfusion imaging have not been met. Therefore, we 
decided that the Plan does not have to pre-approve SPECT myocardial perfusion imaging.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PVP. 
 
You asked the Plan to pre-approve a PVP. You say that this procedure is medically necessary. The Plan denied 
your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PVP is covered when all the criteria listed in the 
Medicare rules section 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 pre-approve a PVP. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the imaging studies do not show an acute 
fracture less than six weeks old. The imaging shows spinal stenosis and other degenerative back pain causes. 
 
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 PVP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a PVP.