Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223-57 billed for date of service September 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that a modifier is allowed. The Plan denied your 
request. The Plan says that an appropriate modifier was not 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 code 99223-57 was billed on the same date of service as major procedure code 26746. If 
evaluation and management services occur on the day of surgery, the physician bills using modifier -57. Based 
on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for procedure code 99223-57 billed for date of service 
September 29, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 31, 2022, billed with 
codes 74230 and 74240. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of imaging services provided. have not been met. The procedure is a barium swallow study, and this 
means that it involves the administration of a substance to the enrollee. Therefore, we decided that the Plan 
does not have to pay for imaging services provided on August 31, 2022, billed with codes 74230 and 74240.
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 the enrollee is stable and suitable for 
transfer to an LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested LTACH services do not meet the requirements for approval. 
 
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 that there is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and acute care hospital are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital 
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level 
of care for any ongoing long term care 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on September 13, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid proof of delivery. The electrodes are supported by the records provided 
because the packing slip and the third-party delivery tracking information have a tracking number to link those 
documents together. The documents meet the Medicare rules for valid proof of delivery. Therefore, we decided 
that the Plan has to pay for the electrodes (A4595) provided on September 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of nasal valve collapse with absorbable nasal 
implant (Latera) 
 
You asked the Plan to pre-approve repair of nasal valve collapse with absorbable nasal implant (Latera). You 
say that the use of the Latera implant for the surgical repair of nasal vestibular stenosis is FDA-approved and is 
medically necessary in this case. The Plan denied your request. The Plan says repair of nasal valve collapse 
with absorbable nasal implant (Latera) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve repair of nasal valve collapse with 
absorbable nasal implant (Latera). Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found provided medical records and 
the current peer-reviewed medical literature do not document that surgical repair of a nasal valve collapse with 
an absorbable nasal implant Latera has been shown in controlled studies to result in long term health benefits in 
patients with nasal obstruction related to seasonal and environmental allergies with eustachian tube dysfunction 
as opposed to standard surgical repair with cartilage grafting.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repair of nasal valve collapse with absorbable nasal implant (Latera) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve repair of nasal valve collapse with 
absorbable nasal implant (Latera)
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital admission beginning on March 17, 
2023. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically 
necessary and reasonable. The Plan denied your request. The Plan says that this admission is not medically 
necessary as the enrollee's needs can be met in an observation level of care. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was admitted to hospital observation on March 15, 2023, from a 
skilled nursing facility with suspected implantable cardioverter-defibrillator (ICD) discharges, weakness and 
diarrhea. The enrollee was then admitted to inpatient care on March 17, 2023. The enrollee has ischemic 
cardiomyopathy with advanced renal failure and is significantly anemic and is not a candidate for further 
cardiac work-up given advanced renal failure and anemia. The review has determined that the record showed 
that at the time of inpatient admission the admitting physician reasonably expected that the enrollees necessary 
hospital care (including earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital admission beginning on March 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy. 
 
You asked the Plan to pre-approve image-guided radiation therapy (IGRT). You say that image-guided 
radiation therapy is a covered service and is medically necessary for this patient. The Plan denied your request. 
The Plan says image-guided radiation therapy for the treatment of the patient's skin cancer is not medically 
necessary and reasonable. The Plan says that superficial skin cancers are visible to the eye, so the use of 
ultrasound images to guide the radiation is not 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 image-guided radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy 
of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow 
reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this patient for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image-guided radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve image-guided radiation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Docetaxel, Carboplatin, and Keytruda. 
 
You asked the Plan to pre-approve Docetaxel, Carboplatin, and Keytruda. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 Docetaxel, Carboplatin, and Keytruda. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested 
use of Docetaxel, Carboplatin, and Keytruda is not FDA-approved for the enrollees diagnosis. 
Recommendations for cancers of unknown primary are to await molecular studies. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Docetaxel, Carboplatin, and Keytruda have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Docetaxel, Carboplatin, and Keytruda.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the observation evaluation and management (EM) services provided 
from March 29, 2022, through April 4, 2022. 
 
You asked the Plan to pay for the observation EM services. You say that these services were correctly billed. 
The Plan denied your request. The Plan says that there is no evidence that the enrollee was a hospital outpatient 
under observation. 
 
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. The Plan's denial rationale was that the codes are not supported as the records 
provided did not show that the enrollee was under outpatient observation. We confirmed with the Plan that the 
facility did submit the claim for this hospital stay as an outpatient claim. As such, the billing of observation EM 
codes for these services is supported. The Plan did not offer an alternate denial rationale. Therefore, we decided 
that the Plan has to pay for the observation evaluation and management (EM) services provided from March 
29, 2022, through April 4, 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 nonadjunctive, nonimplanted continuous glucose 
monitor (CGM) (E2103) and a supply allowance with accessories (A4239). 
 
You asked the Plan to pre-approve a CGM and supply allowance with accessories. You say that you need the 
requested supplies. The Plan denied your request. The Plan says you do not meet the requirements for approval 
of the requested supplies. The records do not show that you treat yourself with insulin injections, or that your 
insulin treatment plan is frequently adjusted. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM and supply 
allowance with accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a nonadjunctive, nonimplanted continuous glucose monitor (CGM) (E2103) and a supply allowance 
with accessories (A4239).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Auvi-Q. 
 
You asked the Plan to pre-approve Auvi-Q. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Auvi-Q.  
 
Benefits for Auvi-Q may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care. 
 
You asked the Plan to pre-approve home health services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records do 
not document any acute, or unstable medical conditions or falls, or injuries which would necessitate any further 
skilled therapy visits beyond what have already been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on September 15, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid proof of delivery. The electrodes are supported by the records provided 
because the packing slip and the third-party delivery tracking information have a tracking number to link those 
documents together. The documents meet the Medicare rules for valid proof of delivery. Therefore, we decided 
that the Plan has to pay for the electrodes (A4595) provided on September 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on May 09, 
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 this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 09, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan provided on May 09, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual swingaway (E1028) and electronic 
connection (E2311). 
 
You asked the Plan to pre-approve the manual swingaway and electronic connection. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says that the requested 
accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are not medically necessary 
when the enrollee does not need to control the power options through the joystick. 
 
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 manual swingaway and electronic 
connection. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that 
the documentation does not support that it is medically necessary to control the requested power options 
through the joystick (drive interface). The enrollee's upper extremity strength and functional ability as 
evidenced by being independent for feeding should be sufficient to control any power options through their 
own switches. The documentation does not reveal that the requested accessories are 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 manual swingaway and electronic connection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the manual swingaway (E1028) and electronic 
connection (E2311).