Persius/hicric huggingface dataset:
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 October 25, 2022. 
 
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 that these tests are 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 October 
25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is a convenience item. This chair can be used in the absence of an illness and 
thus is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under 
certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you have a history of right sided low back pain. Sacroiliac joint (SIJ) injections are 
recommended as an option if you have failed at least 4-6 weeks of aggressive conservative therapy. There 
should be evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease, and at least three 
positive exam findings of SI joint dysfunction should be present on physical exam. In this case, there is no 
documentation on physical examination of three or more positive tests results. The clinical value and 
effectiveness of an SIJ injection in the absence of tenderness and negative provocative testing results have not 
been demonstrated in the peer-reviewed literature. The review has determined that the requested treatment is 
not indicated for your condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3-L5 OLIF (spine procedure). 
 
You asked the Plan to pre-approve L3-L5 OLIF. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are 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 L3-L5 OLIF. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has progression of low back pain and left greater than right leg pain that has been 
occurring over the past year and a half. There is no documentation of spinal instability. Spinal fusion is not 
indicated. Therefore, the enrollee does not meet criteria for the requested services. 
 The Plan uses Local Coverage Determination (LCD) L35008 and L33382 to support their denial. However, 
LCD L35008 is retired and L33382 is not valid for the enrollees home state of Oregon. Therefore, we cannot 
use LCD L35008 or L33382 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3-L5 OLIF have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3-L5 OLIF (spine procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral knee genicular nerve blocks (64454). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that the enrollee deserves comfort from her 
severe knee osteoarthritis, and we have limited to no options at our disposal without the genicular blocks and 
possible nerve ablations. The Plan denied your request. The Plan says the enrollee does not meet coverage 
guidelines for peripheral nerve blocks. The procedure is considered experimental/investigational because it is 
not the standard of care for the enrollee's diagnosis. 
 
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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/ investigational procedure. It is the subject of 
ongoing clinical trials. Therefore, the request is deemed 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral knee genicular nerve blocks (64454).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet the coverage criteria for Injectafer. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services would ensure a safe and medically 
stable discharge. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ruxience, Cyclophosphamide, Doxorubicin, and 
Vincristine. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy requirements have not been met. 
 
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 the services. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found that the plan requires 
a trial of Rituxan, Rituxan Hycela, or Truxima before they will approve the requested drug. In this case, the 
patient has not tried and failed the required drugs. There is no documentation provided indicating that the 
plans 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ruxience, Cyclophosphamide, Doxorubicin, and Vincristine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 90694 and G0008 for date of service September 21, 
2022. 
 
You asked the Plan to pay for codes 90694 and G0008. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 90694 and G0008 are not supported in the medical record. Specifically, this claim was 
submitted with a bill type of 0771, Federally Qualified Health Centers (FQHC), but was not reported wtih 
condition code 65. So, the claim is subjected to be processed under the FQHC PPS but there was no FQHC 
payment code reported on the claim. The claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of codes 90694 and G0008 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 90694 and G0008 for date of service September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); gastrointestinal pathogen, 12-25 targets (87507) provided on December 21, 2022. 
 
You asked the Plan to pay for the infection agent detection, gastrointestinal pathogen, 12-25 targets. You say 
that this service was denied in error. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that gastrointestinal pathogen (GIP) panels utilizing 
NAATs, 12 or more targets, are medically reasonable and necessary for the evaluation of Medicare 
beneficiaries with an immunocompromising medical condition with acute or persistent diarrhea. 
 
We looked at the file and Medicare rules. The provided medical records do not show that the enrollee has an 
immunocompromising medical condition. Based on this information, we decided that Medicare rules for coverage of the infection agent detection, gastrointestinal pathogen, 12-25 targets have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid 
(DNA or RNA); gastrointestinal pathogen, 12-25 targets (87507) provided on December 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for procedure code A0425. You say that you disagree with the 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 3. You billed 367 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code A0425 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code A0425 billed for date of service November 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee is improving but has acute medical issues and 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 
they are not currently receiving but that would be available at the LTACH facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the request is medically 
necessary. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280 also requested 
in this case) and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general) 
is not necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 99306 for June 10, 2022, and code 99309 for June 14, 2022. We 
decided that the Plan does not have to pay for code 99309 for June 10, 2022.  
 
You asked the Plan to pay for procedure codes 99306 and 99309 billed for dates of service June 10, 2022, and 
June 14, 2022. The Plan says that the services are not payable as billed. 
 
We decided that the Plan has to pay for code 99306 billed for June 10, 2022, and code 99309 billed for 
June 14, 2022.  
 
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. The Plan argues that this charge is incidental to another service. However, the 
Plan has not provided documentation indicating which service these codes are incidental to. Without supporting 
documentation, the Plans denial cannot be substantiated. Therefore, we decided that the Plan has to pay for 
code 99306 billed for June 10, 2022, and code 99309 billed for June 14, 2022.  
 
We also decided that the Plan does not have to pay for code 99309 billed for June 10, 2022. 
 
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 99309 
is a column II code to column I code 99306. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99309 billed for June 10, 2022. 
 
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 services provided on November 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that conditions have both an underlying etiology and 
multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a 
coding convention that requires the underlying condition be sequenced first, if applicable, followed by the 
manifestation. Wherever such a combination exists, there is a use additional code note at the etiology code, 
and a code first note at the manifestation code. These instructional notes indicate the proper sequencing order 
of the codes, etiology followed by manifestation.  
 We looked at the file and Medicare rules. Specifically, the record shows that the claim was billed with 
diagnosis code F05. This code has a code first note, which means it is a manifestation code and must be 
sequenced after an etiology code. 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 services 
provided on November 11, 2022.