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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 28, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service March 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services billed on 
December 21, 2022, through December 29, 2022. 
 
You asked the Plan to pay for the SNF services. You say that SNF services should be covered because an 
authorization was obtained for the enrollee's continued SNF stay through December 31, 2022. The Plan denied 
your request. The Plan says the SNF services are denied because the number of units billed does not correspond 
with the date span of the SNF services. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing Part A-covered SNF services, the 
service units billed must contain the number of covered days.  
 
We looked at the file and Medicare rules. You billed the services provided over the course of nine days based 
on the claim submitted but reported eleven covered days with no additional information to account for this 
discrepancy. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) 
services billed on December 21, 2022, through December 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve the medication. You say that Evenity is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says Evenity has been prescribed for an off-label medication, not 
medically accepted use. 
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of prostate cancer and has lytic bone lesions and a 
pulmonary nodule. The Food and Drug Administration has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for 
the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you need this wheelchair 
badly, and it is medically necessary. The Plan denied your request. The Plan says based on Medicare 
guidelines, the group 2 standard power wheelchair (K0823) requested does not meet the requirements for 
approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 group 2 standard power wheelchair. 
Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found you are noted 
to be able to ambulate with the assistance of a walker but have difficulty doing so. The clinical documentation 
is insufficient terms of your level of function with daily activities and your level of mobility. You are noted to 
have intact motor strength but do have bilateral wrist pain, edema, and decreased range of motion. Our 
reviewer found that this may limit your ability to propel a manual wheelchair, but no mobility evaluation has 
been performed and it is not indicated if you cannot propel a manual wheelchair for mobility. There is no 
documentation regarding your ability to transfer and your ability to use a power scooter versus a power 
wheelchair. Our physician reviewer also found that there is insufficient documentation indicating if you can 
safely use the requested power wheelchair and if your home is accessible. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment (90869, 90868, 90867). 
 
You asked the Plan to pre-approve TMS treatment. You say that please review for approval. The Plan denied 
your request. The Plan says the Medicare criteria for coverage has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The requested TMS therapy was ordered by a neurologist and not 
ordered by a psychiatrist per Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of TMS treatment have not been met. Therefore, we decided that the Plan does not have to pre-
approve therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (90869, 90868, 90867).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FoundationOne CDx (F1CDx) test (0037U). 
 
You asked the Plan to pre-approve the genetic testing. You say that please review for prior authorization. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee does not have either recurrent, relapsed, refractory, 
metastatic, or advanced stage III or IV cancer and the provider does not recommend adjuvant chemotherapy. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve FoundationOne CDx (F1CDx) test 
(0037U).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a prosthesis. You say that you are requesting a breast prosthesis mastectomy 
sleeve to help with the enrollee's lymphedema The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
breast prosthesis, mastectomy sleeve (L8010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #14 and a retainer crown 
(D6740) for teeth #13 and tooth #15. 
 
You asked the Plan to pre-approve D6245 and D6740. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says the medical criteria have not been met for this dental work. 
 
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. The Plan covers D6245 and 
D6740 when the services are medically necessary and reasonable.  
 
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 D6245 and D6740. Our physician 
reviewer found there is no documentation showing any neurological or physical disability that would preclude 
the use of a removable appliance. The requested treatment is a viable treatment option. Given the supplied information however, the requested treatment would not meet plan criteria for fixed prosthodontics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6245 and D6740 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve pontics (D6245) for tooth #14 and a retainer crown (D6740) for teeth #13 and tooth 
#15.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FoundationOne Liquid CDx (0239U). 
 
You asked the Plan to pre-approve the laboratory service. You say that please review for prior authorization. 
The Plan denied your request. The Plan says Medicares medical necessity criteria have not been met.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Records indicate that genetic testing with FoundationOne CDx was 
completed on August 28, 2023. The enrollee has previous FoundationOne CDx testing on tissue from this same 
cancer. Based on this information, we decided that Medicare rules for coverage of the laboratory service have 
not been met. Therefore, we decided that the Plan does not have to pre-approve FoundationOne Liquid CDx 
(0239U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Immunoglobulin E (IgE) antibody test (86008). 
 
You asked the Plan to pre-approve the Immunoglobulin E (IgE) antibody test. You say that you would like to 
know if you have this allergy. The Plan denied your request. The Plan says in this case the allergy testing is not 
covered. 
 The Plan follows Medicare rules. Medicare rules say that food allergen testing for patients who present with 
respiratory symptoms other than wheezing and asthma is 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 Immunoglobulin E (IgE) antibody 
test. Our reviewer says that the service is not medically necessary. Our physician reviewer found that food 
allergen testing without asthma/wheezing is not covered by Medicare. Therefore, as you have only complained 
of hives and not asthma/wheezing, the coverage criteria are not 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 the Immunoglobulin E (IgE) antibody test have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Immunoglobulin E (IgE) antibody test (86008).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87506) provided May 15, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
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 service. Our reviewer found the record states that more 
than 11 antigens were tested. There is a more specific code for the number of tests performed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory service (87506) provided May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87491, 87563, 87640, 87653, 
87798, 87641, 87500) provided June 16, 2023. 
 You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
There is a more appropriate lab panel Current Procedural Terminology (CPT) code 81479 that should be billed 
when one or more CPT codes are included in the same panel. Therefore, the service and modifier 59, cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (87481, 
87491, 87563, 87640, 87653, 87798, 87641, 87500) provided June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 21, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's medical condition 
LTACH is most beneficial for them. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
appropriate at this time. Completion of treatment at the current facility is 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Moh's surgery of the left dorsum hand (17311).   
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that Mohs Micrographic Surgery is indicated only when 
the superficial (lateral) or deep margins of the cancer lesion are uncertain clinically and the likelihood of a 
surgical cure and reconstruction would be compromised without use of immediate microscopic examination of 
the surgical margins.  
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that in this 
case, the record indicates that the enrollee has basal cell carcinoma of the hand.    
  
 
 
The record provided does not establish that the superficial (lateral) or deep margins of the cancer lesion are 
uncertain clinically and the likelihood of a surgical cure and reconstruction would be compromised without the 
use of immediate microscopic examination of the surgical margins. The elements of the coverage criteria are 
not satisfied. The requested service is not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Moh's surgery of the left dorsum hand (17311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. The enrollee is not having low blood sugars and is not on medications 
that cause low blood sugar. Although a CGM would likely help the enrollee control their diet based in the rise 
in blood sugars after certain meals/foods, the enrollee does not meet provide the criteria for a CGM 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 the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of osteoarthritis of the knee. The documentation indicates that the 
enrollee improved with physical therapy and does not indicate the failure of a trial of physical therapy. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoassay for analyte other than infectious agent 
antibody or infectious agent antigen; quantitative, not otherwise specified (83520) provided June 9, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
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 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 service. Our reviewer found the review has determined 
that Current Procedural Terminology (CPT) code 83520 (1 unit) remains not supported. The submitted medical 
records did not indicate a complete description of the not otherwise specified code. The order/ lab requisition 
and claim form must include what laboratory test was ordered/requested in order to validate the not otherwise specified code billed. The review has determined that the documentation did not support procedure code 83520 
provided June 9, 2023. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the immunoassay for analyte other than infectious agent antibody or infectious agent antigen; 
quantitative, not otherwise specified (83520) provided June 9, 2023.