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

We decided that the Plan does not have to pre-approve the fold down push handles (K0108).

You asked the Plan to pre-approve the fold down push handles. You say that the item is medically necessary.
The Plan denied your request. The Plan says this item does not primarily serve a medical purpose

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve the fold down push handles (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87801, 87500, 81003, 87653, 87481, 
87641 and 87798) provided on April 17, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says out-of-network services are only covered in 
certain limited circumstances which are not met in this case. Neither the performing or referring providers are 
in-network with the Plan. In addition, codes 87653, 87481, 87641 and 87798 are included in code 87801 and 
would not be billed separately. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided/referred the items/services at issue in this appeal. The Plan did not pre-
approve the item/service at issue. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (87801, 87500, 
81003, 87653, 87481, 87641 and 87798) provided on April 17, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 20, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that codes 0012M and 0013M for Cxbladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on March 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit for the evaluation and 
management of an established patient billed with code 99347 for date of service April 19, 2023. 
 
You asked the Plan to pay for the home or residence visit for the evaluation and management of an established 
patient. 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 code 99347 is used to report E/M services 
furnished to a patient residing in his or her own private residence and not any type of facility. 
 
 We looked at the file and Medicare rules. Review of the file shows that the claim submitted did not include a 
place of service. Without this required information, the claim cannot be paid as billed. Based on this 
information, we decided that Medicare rules for coverage of the home or residence visit for the evaluation and 
management of an established patient have not been met. Therefore, we decided that the Plan does not have to 
pay for the home or residence visit for the evaluation and management of an established patient billed with 
code 99347 for date of service April 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy and mastectomy for gynecomastia. 
 
You asked the Plan to pre-approve a panniculectomy and mastectomy for gynecomastia. You say that the 
requested surgeries are not medically necessary. The Plan denied your request. The Plan says the enrollee 
would benefit from these procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 panniculectomy and mastectomy for 
gynecomastia. Our reviewer says that this procedure is not medically necessary. Our reviewer found the record 
provided does not document the presence of intertrigo refractory to conservative treatment.  The record 
provided does not document that medical causes of gynecomastia have been eliminated as required by the 
rules.    
 
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 panniculectomy and mastectomy for gynecomastia have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a panniculectomy and mastectomy for 
gynecomastia.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee is not a candidate for other anabolic 
agents.  The Plan denied your request. The Plan says that the enrollee is required to be postmenopausal. 
 
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 Evenity. Our physician reviewer found 
that the enrollee has multiple comorbidities including severe osteoporosis, multiple fractures, end stage renal 
disease, and kidney/pancreas transplant. Evenity has been requested to help manage severe osteoporosis. Other 
anabolic choices were contraindicated. The drug in question is indicated for treatment of osteoporosis. The 
contraindications do not include premenopausal women. The documentation made clear that the enrollee does 
not plan on having more children and that she acknowledged the risks. Additionally, the documentation 
explained how the other drug choices were in fact contraindicated due to concurrent medical conditions. In 
summary, the documentation supports that the requested drug is reasonable and necessary for this 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 Evenity have been met. Therefore, we decided that the Plan has to pre-approve 
Evenity.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to a long term acute care 
hospital is medically necessary. The Plan denied your request. The Plan says admission to a long term acute 
care hospital 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 the enrollee is receiving appropriate care in the current acute care setting provided by 
the Health Plan. Documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 for date of service March 28, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, the order/lab requisition 
must include what laboratory test was ordered/requested in order to validate the code billed. Without this 
information, the code billed cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87798 for date of service March 28, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Affinity skin substitute. 
 
You asked the Plan to pre-approve Affinity skin substitute. You say that the enrollee has a diabetic foot ulcer 
that has been slow to heal despite wound care. The Plan denied your request. The Plan says that the records do 
not show that the enrollee has received all aspects of standard wound care. 
 
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 Affinity skin substitute. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation supports that the enrollee has been treating an ulceration to the 
plantar aspect of the right hallux since at least January 4, 2023. The diabetic foot ulceration has been present 
for at least 8 months. This certainly puts a diabetic patient at risk. The enrollee has undergone treatment 
including offloading, diabetic shoes, diabetic insoles, wound debridement, dressings, and antibiotics. It appears 
that this diabetic enrollee has exhausted all of the standard wound care treatments and still possesses an open 
ulceration to the right hallux after at least 8 months. Advanced wound care including Affinity skin substitute is 
medically reasonable and necessary 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 Affinity skin substitute have been met. Therefore, we decided that the Plan has 
to pre-approve Affinity skin substitute.  
 
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 procedure code 81456 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. 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 two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service January 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided on July 27, 2022. 
 You asked the Plan to pay for the inpatient hospitalization. The Plan denied your request. The Plan says the 
clinical records do not support a reasonable expectation that the patient would require inpatient care extending 
beyond 2 midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient presented for an elective, scheduled bilateral laminectomy, medial 
facetectomy, and foraminotomy. The documentation described the patient tolerated the procedure without 
complication and was able to walk, eat, and void soon after the procedure with stable vitals. Our reviewer also 
found that it was not expected that the patient would have required inpatient treatment that would have likely 
crossed 2 midnights and there is not risk of an adverse event at the time of admission.  
 
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 inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint (64625). 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that you are asking for 
reconsideration in this case as an exception because of the enrollees underlying anatomic abnormality and 
intensity of pain. The Plan denied your request. The Plan says the request does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that Sacroiliac Joint (SIJ) Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 The requested radiofrequency ablation is not considered reasonable and necessary and is excluded from 
Medicare coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sacroiliac joint radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation to the sacroiliac joint (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service May 5, 2023.   
You asked the Plan to pay for procedure code 88377. You say that the referring physician felt it medically 
necessary to order this test as a panel of 6 probes in order to diagnose or rule out Leukemia, lymphoma and 
other myelodysplastic syndromes. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service May 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA DISC allograft procedure. 
 
You asked the Plan to pre-approve the requested services. You say that conventional treatments have not 
resulted in adequate pain relief. The Plan denied your request. The Plan says there is little evidence this is 
appropriate for the enrollee's back pain. 
 
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 requested services. Our physician 
reviewer found that the requested allograft procedure is experimental for back pain. Therefore, the request is 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VIA DISC allograft procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.  
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are necessary. 
The Plan denied your request. The Plan says the additional PT visits are not reasonable or necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had 20 sessions of PT as of September 1, 2023. The 
enrollee has nearly normal motor strength in the lower extremities and their progress with therapy has largely 
plateaued. The enrollee can continue with a home exercise program. Therefore, the 10 additional PT visits are 
not 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the most 
appropriate. The Plan denied your request. The Plan says the denial of LTACH services is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate services in the current acute care setting. 
Continued care in the current hospital is appropriate until stable for transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper. You asked the Plan to pre-approve the medication. You would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Although an oral anti-emetic such as Prochlorper may be covered by Medicare 
Part B, this request does not fall under Medicare Part B coverage because oral anti-emetic drugs that are not 
administered with chemotherapy treatment and initiated within 2 hours of the administration of chemotherapy 
and may not continue for a period exceeding 48 hours from that time and will not be used as a full therapeutic 
replacement for IV anti-emetic drugs that would have been administered at the time of the chemotherapy 
treatment are not covered by Part B. Therefore, we decided that the Plan does not have to pre-approve 
Prochlorper.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.