Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional accessories for a prosthesis (L5828, L5845, L5848, 
L5856). 
 
You asked the Plan to pre-approve the items. You say that this was medically necessary. The Plan denied your 
request. The Plan says that while the enrollee's physician documents that the enrollee has K3 potential, he does 
not give any reason why a microprocessor knee is medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 items. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that not only does the medical record amply satisfy Medicare policy in demonstrating this enrollee has a 
K3 functional level and has specific needs for the requested components, but the plan also attempts to create a 
more restrictive policy for defining K3 function than Medicare policy would allow. In contrast to the broad, 
inclusive K3 criteria from the LCD that generally describe the average Medicare beneficiary who lives 
independently at home and in the community, the Plans denial letter sets more stringent requirements than 
Medicare. In its own definition of the K3 level, the Plan seeks to create strict use-case criteria with a level of 
specificity that does not appear in the LCD - You must need to do more than simple walking...You must need to cross different barriers (such as walking long distances or walking on steep or slippery surfaces). The 
certified prosthetist/orthotist (CPO) and prescribers notes from January 2023 and multiple visits in 2022 more 
than satisfy Medicare requirements for documenting the enrollee's K3 functional potential and specific need for 
the new prosthesis as requested. Medicares policy recognizes that microprocessor knees and flex-walk feet are 
part of the basic standard of care for all community above knee amputee ambulators given that the evidence of 
their benefits and superiority to less sophisticated alternatives are so well proven and long standing. 
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
additional accessories for a prosthesis (L5828, L5845, L5848, L5856).  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show recent injury to the knee, surgery to the knee, or knee 
instability on physical exam. 
 
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 item. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is ambulatory, has an ICD-10 group 4 diagnosis code (M17.12 - unilateral primary 
osteoarthritis of knee), has a recent knee injury from forced range of motion outside of normal anatomical 
movement while working with horses, and has varus instability both on physical exam and, more compellingly, 
on x-ray where he appears to be bone-on-bone in the medial compartment. The pain from that kind of 
deformity necessarily causes functional instability.  
 
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 item have been met. Therefore, we decided that the Plan has to pre-approve 
a knee orthosis (L1851).  
 
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: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure codes 87481 and 87653) rendered on 
December 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the codes are not reimbursable as a separate charge. 
 
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 
the denied codes is: 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that CPT codes 87653 and 87481 are 
supported by the medical records as separately identifiable. The results show that they were tested for and were 
negative. According to CPT lab coding guidelines, for each specific organism nucleic acid detection from a 
primary source, see 87471-87660. For detection of specific infectious agents not otherwise specified, see 
87797, 87798, or 87799 1 time for each agent. For detection of multiple infectious agents not otherwise 
specified which report a single result, see 87800, 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure codes 87481 and 87653) rendered on December 16, 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 pre-approve care and services with an out-of-network (OON) 
oncologist at a tertiary level of care facility.  
 
You asked the Plan to pre-approve care and services with an OON oncologist at a tertiary level of care facility. 
You say that you were diagnosed with a rare type of bone marrow cancer for which research and care treatment 
is rapidly developing and changing. You say that regular general oncologists do not stay up to date on this 
rapidly changing field as well as a Myeloproliferative Neoplasm (MPN) specialists do. You say that your 
primary care physician and your general oncologist agree that it is medically necessary for you to see an MPN 
specialist. You say that the network oncologists the Plan referred you to are all general oncologists and are not 
specialized in treating MPN.  The Plan denied your request. The Plan says there is no indication from the 
documentation that the requested OON care is needed for treatment of the enrollee's condition.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 care and services with an OON 
oncologist at a tertiary level of care facility. Our reviewer says that the criteria for OON coverage have not 
been met.  Our physician reviewer found the Plans denial is medically justified on the basis that it is offering 
adequate care to meet the enrollees medical needs through referral to their in-network non-tertiary level 
providers. A tertiary level of care is not medically reasonable and necessary at this point. Myelofibrosis is a 
rare condition, but hematologists/oncologists have training to treat this disease unless the enrollee has a very 
complicated case, which does not appear to be the case at this point. The Plan has shown that they have in-
network providers who meet the Standards of Care required for treatment of the enrollee's 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 care and services with an OON oncologist at a tertiary level of care facility have 
not been met. Therefore, we decided that the Plan does not have to pre-approve care and services with an out-
of-network (OON) oncologist at a tertiary level of care facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 7, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were appropriate for the 
patient's condition. The Plan denied your request. The Plan says you billed this claim with an inappropriate pair 
of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of I69.320 and R47.01. Code I69.320 is an Excludes1 code 
under code R47.01, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
December 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support a comprehensive history, exam, or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on December 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the trans-esophageal echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve the TTE. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the TTE. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found documentation at this time would not point to a change in status that would support the medical necessity 
of a repeat TTE. Clinical guidelines do not support repeating a TTE with no intervening change in clinical 
status or new signs, symptoms or physical findings. 
 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 TTE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the trans-esophageal echocardiogram (TTE) (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and an oxygen device. 
 
You asked the Plan to pre-approve the devices. You say that this was ordered by the doctor in the emergency 
room when you were discharged. The Plan denied your request. The Plan says a sleep study is needed to 
determine if these devices are indicated. 
 
The Plan must follow Medicare rules. The rules say that oxygen and CPAP are coverable when medically 
necessary for patients who meet certain requirements.  
 
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 devices Our reviewer says that the 
requested devices are not medically reasonable or necessary. Our physician reviewer found that CPAP and 
oxygen are not medically necessary. The enrollee has severe obesity, diabetes mellitus, heart failure with 
preserved ejection fraction (HFpEF), sick sinus syndrome, and dyspnea. The enrollee was hospitalized in 
March for heart failure. The enrollee is requesting oxygen since discharge. A progress note indicates that the 
enrollee had a sleep study that showed obstructive sleep apnea (OSA), but there is no documentation of that. 
There is no mention of OSA in the visits after discharge. The evaluation by a respiratory therapist showed 
resting Sp02 98% on room air, with no desaturation with arm exercises. The enrollee refused overnight 
oximetry. Therefore, these devices are not 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 devices have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device and an oxygen device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure code 88291 rendered on 
December 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no specific rationale for the additional units.  
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 88291 is "Cytogenetics and molecular cytogenetics, 
interpretation and report." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided documentation did 
not include the prescribing physician's reason and explanation for why these were needed in this clinical 
situation to help support this request. Therefore, the additional units will be considered not medically necessary 
at this time based on the provided documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional units of procedure code 88291 rendered on December 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 25, 2022, to 
November 21, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 25, 2022. The NOA was not received by the Plan until 
December 12, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from October 25, 2022, to November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee's cervical facet joint 
radiofrequency ablation increased their ability to complete activities of daily living and provided 60% pain 
relief for five months. The Plan denied your request. The Plan says repeat radiofrequency ablation is not 
medically necessary.  
  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is concern for acute cervical radiculopathy and the prior cervical RFA 
procedures have not provided sufficient or durable pain relief for the enrollee. Therefore, it is not appropriate to 
proceed with repeat RFAs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 You asked the Plan to pre-approve Udenyca. 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. 
 
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 Udenyca. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.