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

 
We decided that the Plan has to pay for laboratory services (36415, 84134, P9604) provided on July 21, 2022. 
 
You asked the Plan to pay for laboratory 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 indicates that the enrollee was in a skilled nursing facility 
(SNF) stay that overlaps the date of service at issue in this case. The Plan states that the SNF reported a Place 
of Service (POS) code of 31, indicating a SNF stay covered by Medicare Part A. Laboratory services provided 
during a Part A-covered SNF stay must be paid for by Part A. 
 
However, we were unable to locate POS code 31 on the provided claim for the enrollee's SNF stay. In response 
to a request for clarification, the Plan stated that its decision was based on the SNF claim having been reported 
on Type of Bill (TOB) 211. We found that this TOB code does not specify the source of payment. The Plan has 
not provided documentation of payment by Part A for the enrollee's SNF stay. 
 
It is the Plan's responsibility to support its denial with evidence. In this case, the Plan's denial has not been 
supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for laboratory services 
(36415, 84134, P9604) provided on July 21, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you disagree with 
the denial and have attached medical records for review. The Plan denied your request. The Plan says the 
request is not medically necessary because your records do not show you have been seen on a regular basis by 
a licensed healthcare worker or documentation that the mattress is still 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 a powered pressure-reducing air 
mattress. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found per LCD33642: continued use of a group 2 support 
surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the 
medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the 
use of the group 2 support surface is reasonable and necessary for wound management. The record does not 
show the status of the ulcer or the treatment plan to improve ulcer healing. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on May 
31, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that the service should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $70 copayment for a diagnostic mammogram. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a diagnostic mammogram provided on May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from December 26, 
2022 to December 31, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the diagnosis billed. The Plan denied your request. The Plan says the review did not 
find sufficient documentation to clinically validate the diagnosis of J15.6 (Pneumonia due to other gram-
negative bacteria) as the principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, J15.6, defined as 
Pneumonia due to other Gram-negative bacteria. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the submitted DRG is not 
supported. Our physician reviewer found in this case, there was no evidence of a gram-negative organism in the 
sputum culture with gram stain. Blood culture showed no growth after 4 days as per microbiology result from 
the medical records. Our reviewer found that a urine antigen test was not done. Our physician reviewer also 
found that the documentation did not support diagnosis code J15.6.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from December 26, 2022 to December 31, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the patient needs to start this treatment as soon as 
possible. The Plan denied your request. The Plan says this drug is not being prescribed in a medically accepted 
reasonable and necessary manner. 
 
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 Retacrit. Our reviewer says that 
Retacrit is not medically reasonable and necessary for the patient. Our physician reviewer found the patient has 
metastatic prostate cancer and multifactorial anemia. Anemia of chronic kidney disease contributing and 
treatment with erythropoietin is recommended. Our reviewer found that on September 29, 2023, the patient's 
hemoglobin was 8 and their creatinine was 1.5 with an estimated glomerular filtration rate of 47 to 57. The 
patient's iron saturation was 11% with a ferritin of 76. Other treatable causes of anemia should be corrected 
prior to initiation of Retacrit. Labs indicate iron deficiency anemia. Our physician reviewer also found that the 
treatment at this point is not reasonable or medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral augmentation (22514). 
 
You asked the Plan to pre-approve vertebral augmentation. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage 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 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 vertebral augmentation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service in the enrollee's specific clinical scenario. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 vertebral augmentation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vertebral augmentation (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two transforaminal epidural steroid injections of the 
lumbar or sacral area (64483 x2). 
 
You asked the Plan to pre-approve the transforaminal epidural steroid injections. You say that the patient needs 
this injection done because they have had radicular back pain for more than three months and also have 
difficulty doing daily activities. The Plan denied your request. The Plan says this request cannot be approved 
because there is no documented improvement in function from baseline for at least 3 months after the last 
epidural injection. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months. 
 
 
 
 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 transforaminal epidural steroid 
injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
patient had a transforaminal epidural steroid injection on August 10, 2023, which provided less than 50% relief 
of pain. Our reviewer also found that there is no documentation provided indicating that the requested epidural 
steroid injections will be performed using a different approach, level and/or medication if appropriate. 
 
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 transforaminal epidural steroid injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve two transforaminal epidural steroid injections of the lumbar 
or sacral area (64483 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309-25 rendered on June 8, 2023. 
 
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 code 99309 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 30 minutes must be met or exceeded." 
 
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 medical records provided 
indicates that procedure code 99309 falls within the global period of CPT 11042, 11043, and 11044, which was 
performed on June 8, 2023 by the same provider. This is also indicated on the billing history. The medical 
records do not include sufficient documentation to support CPT 99309 as a significant, separately identifiable 
evaluation and Management service, therefore it is not appropriate to use a 25 modifier with 99309 for date of 
service June 8, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99309-25 rendered on June 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 11644, 15275, 69100, 88305, 88331, C1762, J0690, 
J2405, J2704, J3010, J3490, and J7120 for date of service April 24, 2023. 
 
You asked the Plan to pay for codes 11644, 15275, 69100, 88305, 88331, C1762, J0690, J2405, J2704, J3010, 
J3490, and J7120. 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 11644, 15275, 69100, 88305, 88331, C1762, J0690, J2405, J2704, J3010, J3490, and 
J7120 are not payable as billed. Specifically, code 15275 is listed as a high-cost skin substitute application 
procedure. However, was billed without an appropriate high-cost skin substitute product code. This created an 
OCE edit, which denies the entire claim. Based on this information, we decided that Medicare rules for 
coverage of codes 11644, 15275, 69100, 88305, 88331, C1762, J0690, J2405, J2704, J3010, J3490, and J7120 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 11644, 15275, 69100, 
88305, 88331, C1762, J0690, J2405, J2704, J3010, J3490, and J7120 for date of service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS device. 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 CardioMEMS device. 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 recurrent congestive heart failure (CHF). The CardioMEMS device 
was approved by the FDA in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on 
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection 
fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, 87798, 87640, 87500, 87651, 
87471, 87493, 87529, 87563, 87653, and 87561 billed for May 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 
87563, 87653, and 87561 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87641 is infectious agent 
detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe 
technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The definition of code 87640 is infectious 
agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The 
definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance 
(eg, enterococcus species van A, van B), amplified probe technique. The definition of code 87651 is infectious 
agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique. 
The definition of code 87471 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, 
amplified probe technique. The definition of code 87493 is infectious agent detection by nucleic acid (DNA or 
RNA); Clostridium difficile, toxin gene(s), amplified probe technique. The definition of code 87529 is 
infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique. 
The definition of code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma 
genitalium, amplified probe technique. The definition of code 87653 is infectious agent detection by nucleic 
acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 87561 is 
infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique. 
 
We find that CPT codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, 87653, and 
87561 are not supported in the medical record. Specifically, the records show that a panel of tests was 
performed and there is a more appropriate singular code for these services. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 
87529, 87563, 87653, and 87561 billed for May 11, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Eylea. 
 You asked the Plan to pre-approve Eylea. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Avastin before it will approve Eylea. 
 
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 Eylea. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Eylea. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Avastin. The record does not show that this drug 
would likely be less effective and/or 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Eylea.