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

 
We decided that the Plan has to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that the requested drug is medically necessary for the 
enrollee's treatment for low white blood cell count and cancer. The Plan denied your request. The Plan says that 
the accepted use of this drug for the enrollee's condition requires that they have received myelosuppressive 
chemotherapy 24 to 72 hours prior to starting Granix injections. 
 
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 Granix. Our reviewer says that the 
criteria for coverage have been met.  Our physician reviewer found the enrollee has a locally advanced left 
breast cancer, is estrogen receptor (ER)/progesterone receptor (PR) negative and human epidural growth factor 
receptor 2 (HER2) positive and has been receiving neoadjuvant on Taxotere, Carboplatin, Herceptin, Perjeta 
(TCHP.) For her third cycle, Neulasta was held due to a white blood cell (WBC) count of 9. However, 1 week 
later her WBC was 1.3 with an absolute neutrophil count (ANC) of 130, putting her at significant risk of 
neutropenic fever. Granix if FDA approved to decrease the incidence of infection (neutropenic fever) in 
patients with non-myeloid malignancies, receiving myelosuppressive chemotherapy associated with a 
significant incidence of severe neutropenia with fever. This patient meets these criteria, and the requested drug 
is reasonable and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have been met. Therefore, we decided that the Plan has to pre-approve 
Granix.  
 
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 procedure code 69990 billed for date of service April 24, 
2023.  
 
You asked the Plan to pay for procedure code 69990. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 69990 is bundled into payment for code 63030. 
 
 
 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, we have confirmed that code 69990 
is a column II code to column I code 63030 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 69990 billed for date of service April 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 49596, A4369, C1781, J0690, J1170, J1885, J2370, 
J2704, J3010, and J3490 for date of service March 17, 2023. 
 
You asked the Plan to pay for codes 49596, A4369, C1781, J0690, J1170, J1885, J2370, J2704, J3010, and 
J3490. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that codes 49596, A4369, C1781, J0690, J1170, J1885, J2370, J2704, J3010, and J3490 are not 
supported in the medical record. Specifically, code 49596 is an inpatient only procedure code. This service was 
billed incorrectly on an outpatient claim. In addition, due to the billing of an inpatient procedure code all other 
line items billed on the claim were denied as service on same day as inpatient procedure. Based on this 
information, we decided that Medicare rules for coverage of codes 49596, A4369, C1781, J0690, J1170, J1885, 
J2370, J2704, J3010, and J3490 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes 49596, A4369, C1781, J0690, J1170, J1885, J2370, J2704, J3010, and J3490 for date of service 
March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377), 
positioning/safety belt (E0978), power standing system (E2301), attendant control (E2331), removable knee 
support (K0108), optional armrest (K0108), Corpus VS legrest (K0108), push handles (K0108), and cup holder 
(K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these are medically necessary for 
the enrollee. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary. 
The Plan says an attendant control is not covered when a beneficiary-operated drive control system is covered. 
The Plan says power standing system, cupholder, and push handles do not have a medical purpose and 
therefore are not covered. The Plan says the armrests and positioning/safety belt are included in the requested 
wheelchair. The Plan also says the legrest extension tube and mounting hardware are miscoded. 
 
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 wheelchair accessories. Our 
reviewer says that the requested wheelchair accessories are not medically necessary. Our physician reviewer 
found the documentation shows the enrollee has sufficient strength and function in upper extremities to manage 
standard power drives. The reviewer found that an attendant control is not provided when the power wheelchair 
has user control. The armrests and safety belt are included with the power wheelchair. The reviewer also found 
that provided records from the prescribing practitioner and the evaluating occupational therapist in this case do 
not document necessity of the removable knee support and legrest extensions. Therefore, the reviewer found 
that the requested accessories 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 wheelchair accessories have not been met. Additionally, the power standing 
system, cupholder, and push handles do not serve a medical purpose. Therefore, we decided that the Plan does 
not have to pre-approve upgraded electronics (E2311, E2313, E2377), positioning/safety belt (E0978), power 
standing system (E2301), attendant control (E2331), removable knee support (K0108), optional armrest 
(K0108), Corpus VS legrest (K0108), push handles (K0108), and cup holder (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, 83789 and G0480 for date of service 
March 15, 2023. 
 You asked the Plan to pay for procedure codes 80307, 83789 and G0480. 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. 
 
We find that CPT code 80307, 83789 and G0480 is not supported in the medical record. Specifically, the 
documentation submitted does not include an order that specifically lists what tests are to be performed in the 
custom panel; therefore, codes 80307 and G0480 cannot be verified. In this case, we have confirmed that code 
83789 is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier 
to bypass the edit. Based on this information, we decided that Medicare rules for coverage of procedure codes 
80307, 83789 and G0480 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80307, 83789 and G0480 for date of service March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration as 
the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 billed for date of service April 25, 
2023.  
 You asked the Plan to pay for procedure code 64494. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64494 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64494 billed for date of service April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis procedure (81003) provided on October 31, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting this claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 urinalysis procedure (81003) provided on 
October 31, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for code Q9966-JW for date of service April 21, 2023. 
 
You asked the Plan to pay for Q9966-JW. You say that Q9966-JW should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says that Q9966-JW is denied because 
records indicate a single use vial of low osmolar contrast material, 200-299 milligram(mg)/milliliter(ml) iodine 
concentration, per ml was administered and there is a more appropriate single use vial, low osmolar contrast 
material, 100-199 mg/ml iodine, that could have been used. 
 
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 Q9966-JW is discarded units of low osmolar contrast material, 200-299 mg/ml iodine concentration, per 
ml. 
 
We find that CPT code Q9966-JW is supported in the medical record. Specifically, documentation indicates 
that 3 ml of omnipaque 240 contrast was injected, and the remaining 47 units of contrast were withdrawn and 
discarded. Omnipaque 240 is categorized as low osmolar contrast material, 200-299 mg/ml iodine 
concentration, per ml. The National Drug Code (NDC) billed by the provider was 00407-1412-30, which also 
coincides with Q9966-JW. Therefore, Q9966-JW was appropriate to document these discarded units. Based on 
this information, we decided that Medicare rules for coverage of Q9966-JW have been met. Therefore, we 
decided that the Plan has to pay for code Q9966-JW for date of service April 21, 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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 33681 and 33463. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 33208-GZ.  
 
You asked the Plan to pay for procedure codes 33681, 33463, and 33208-GZ provided on October 21, 2022. 
You say that you would like the Plan to reconsider their denial of payment. The Plan says that the services are 
not covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 33681 and 33463.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 33681 and 33463.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
33208-GZ. 
 
The Plan must follow Medicare rules. Medicare rules state that items submitted with a GZ modifier shall be 
denied automatically and will not be subject to complex medical review. 
 
We find that CPT code 33208 is not supported in the medical record. Specifically, this service includes the GZ 
modifier, which by definition means that these services do not meet the criteria for Medicare coverage. Based 
on this information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
33208-GZ have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code(s) 33208-GZ. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Barostim Neo System in the 
setting of congestive heart failure have not been demonstrated in the peer-reviewed literature. 
 
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 Barostim Neo device. Our reviewer 
says that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. Our physician reviewer found at this 
time, the Barostim Neo system would not be considered medically appropriate and necessary 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 the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (0266T, C1825).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Grafix PRIME. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary or within the standard of care. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation supports that this enrollee has been suffering with an open wound to the 
left lower leg since May 27, 2021. From that time, they have received routine wound care, dressings, and 
compression stockings. During a medical visit dated 6/5/23, after having failed a prolonged wound care 
regiment, the enrollees physician requested application of Grafix Prime to the lower leg wound. It is well 
documented that this patient has failed considerable and extensive wound care for their left lower leg wound. It 
is reasonable for the Grafix Prime skin substitute to be applied to improve the healing of this 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve Grafix PRIME.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on February 14, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says there is insufficient information in the 
record to support the services requested. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the physician order indicates that a "Urine MCT (All-in-One)" test was requested, but there is no 
documentation to show what tests are included in this panel. Without this information, we cannot verify that the 
services provided were medically necessary and were requested by the enrollee's treating physician. Therefore, 
we decided that the Plan does not have to pay for drug testing (G0483) provided on February 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Leqembi is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 
Leqembi is not medically necessary.  Our physician reviewer found that while the decision to use Leqembi has 
been documented, the results of testing leading to the diagnosis supporting that decision are not identified for 
review. As such, the medical necessity for the requested drug has not been established. 
 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 Leqembi.