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

 
We decided that the Plan does not have to pay for procedure codes 27606, 38220, 73610 and 73630 rendered 
on December 30, 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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 27606: 
 
Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia  
CPT 38220: 
 
Diagnostic bone marrow; aspiration(s) 
 
CPT 73610: 
 
Radiologic examination, ankle; complete, minimum of 3 views 
 
CPT 73630: 
 
Radiologic examination, foot; complete, minimum of 3 views 
 
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 in terms of CPT 27606, the procedure report describes a more comprehensive 
procedure performed, triple arthrodesis, as tenotomy would be considered an integral component. 
 
In terms of CPT 38220, the procedure report does not support a diagnostic bone marrow aspiration. Therefore, 
this code cannot be verified. 
 
In terms of CPT 73610 and 73630, the procedure report describes radiology services provided post-procedure 
for follow-up of the primary procedure - CPT 28715. These codes would be inclusive of the primary procedure. 
 
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 procedure codes 27606, 38220, 73610 and 73630 rendered on December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD Panel (0312U) provided on August 11, 
2022.  
 
You asked the Plan to pay for the AVISE CTD Panel. You say that this testing was determined to be medically 
necessary by the enrollee's treating physician. The Plan denied your request. The Plan says this panel is 
considered unproven as its clinical value and effectiveness have not been established in the peer-reviewed 
literature. It has not been clearly shown to alter disease prognosis or treatment outcomes and has not been 
proven to be superior to alternative tests and measures of disease activity.  
 
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 pay for the AVISE CTD Panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this panel is considered unproven as its clinical value and effectiveness have not 
been established in the peer-reviewed literature. The review has determined that this testing was 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 AVISE CTD Panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the AVISE CTD Panel (0312U) provided on August 11, 2022.
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 need inpatient rehabilitation to regain mobility 
after falling and breaking your ankle. The Plan denied your request. The Plan says you do not meet the 
guidelines for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
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 appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage. 
 
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 Opdivo. Our reviewer says that the 
requested use of Opdivo is not FDA-approved for the enrollees diagnosis. Our physician reviewer found the 
use of Opdivo is not supported by one of the major drug compendia or by clinical research. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care services (99222) billed for date of service January 
25, 2023. 
 
You asked the Plan to pay for initial hospital care services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial states that the provider must report a modifier with 
the billed CPT code to indicate a "separate and distinct service," if applicable. However, no such requirement is 
found in the rules cited by the Plan. It is the Plan's responsibility to support its denial with evidence. In this 
case, the Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan has 
to pay for initial hospital care services (99222) billed for date of service January 25, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the urinary tract infection (UTI) panel provided November 
21, 2022.   
 
You asked the Plan to pay for  the laboratory service. You say that you are appealing this claim with medical 
records to show medical necessity for why these services was performed.  The Plan denied your request. The 
Plan says the requested testing exceeds the enrollee's medical needs and 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee underwent PCR testing for a UTI. The review 
of the medical literature and clinical practice guidelines, including by the Infectious Disease Society of America and Healthcare Infection Control Practices Advisory Committee (HICPAC), state standard of care for 
evaluation of urinary tract infection includes a urinalysis, followed by a urine culture and susceptibility studies. 
There is a lack of support for the clinical utility of large multiplex PCR urinary tract infection panel tests. The 
review has determined that the items/services at issue in this case were 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for  the urinary tract infection (UTI) panel provided November 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kadcyla. 
 
You asked the Plan to pre-approve Kadcyla. The Plan denied your request. The Plan says the enrollee does not 
meet the coverage criteria.  
 
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 Kadcyla. Our reviewer says that the 
requested use of Kadcyla is not FDA-approved for the enrollees diagnosis. Our physician reviewer found that 
there is no evidence of progression outside of rising tumor markers and the enrollee has not received 
trastuzumab based therapy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kadcyla have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kadcyla.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried the preferred drugs. 
 
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 Leqvio. Our reviewer says that the 
requirements for coverage of Leqvio have not been met. Our physician reviewer found the Plan requires a trial 
of drug Praluent or Repatha before they will approve Leqvio. You have not tried and failed the required drugs 
There is no indication the required drugs would likely be less effective or have adverse effects for the you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99306) rendered 
on September 15, 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 Current Procedural Terminology (CPT) code 99306 remains 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. 
 
In this case, the CPT Code Manual definition of code 99306 is "Initial nursing facility 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, 45 minutes are spent at the bedside and on the patient's facility 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 CPT 99306 was not supported as 
there was specifically no 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 nursing facility care (procedure code 99306) rendered on September 15, 2022.
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 reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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 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: 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the request 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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until no acute services are required and then be 
transferred or discharged to a lower level of care for any ongoing needs. 
  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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The 
Plan denied your request. The Plan says the requested Retacrit 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 Retacrit. Our reviewer says that the 
requested Retacrit is not medically necessary. Our physician reviewer found provided records in this case do 
not document that other causes of anemia have been ruled out including B-12, folate and iron deficiencies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) scan of face received on November 8, 
2022. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that there was no coverage for the services. 
 
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. we requested medical records, but the plan did not send us any, therefore the 
plan did not show that their denial was correct. Therefore, we decided that the Plan has to pay for the computed 
tomography (CT) scan of face received on November 8, 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.