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

 
We decided that the Plan has to pay for the bevacizumab-awwb (Q5107) and chemotherapy administration 
(96413) provided on April 12, 2022. 
 
You asked the Plan to pay for the bevacizumab-awwb and chemotherapy administration. You say that you 
believe these services were appropriate based on the enrollee's past medical history. The Plan denied your 
request. The Plan says that coverage for charges for, or in connection with, services or supplies that we 
determine to be experimental, investigational, cosmetic or not generally recognized according to professional 
standards of safety and effectiveness in the United States for diagnosis, care, or treatment is excluded under the 
enrollee's plan. 
 
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 pay for the bevacizumab-awwb and chemotherapy 
administration. Our reviewer says that the bevacizumab-awwb and chemotherapy administration were 
medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
bevacizumab-awwb (Q5107) and the chemotherapy administration (96413) are not FDA-approved for the 
enrollees diagnosis. The use is supported by one of the major drug compendia or by clinical research that 
appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal for radiation necrosis 
after treatment for metastatic disease. Our reviewer found that the use is not listed as not indicated, not 
supported or not recommended in any of the compendia. Our physician reviewer also found that the 
documentation does support that the requested drug is safe and effective and otherwise 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 the bevacizumab-awwb and chemotherapy administration have not been met. 
Therefore, we decided that the Plan has to pay for the bevacizumab-awwb (Q5107) and chemotherapy 
administration (96413) provided on April 12, 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 an ultra-lightweight wheelchair (K0005, E2203, E0971, 
E2202, E0978). 
 
You asked the Plan to pre-approve a wheelchair. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee's weight is over 
400 pounds and does not meet the criteria for the requested chair. 
 
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 wheelchair. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per therapy notes the enrollee requires a manual wheelchair but weighs well over 250 pounds at 
378 pounds. Ultralight wheelchairs are not designed for persons over 250 pounds per LCD L33788. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ultra-lightweight wheelchair (K0005, E2203, E0971, E2202, E0978).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798 and 87481 billed for date of 
service December 13, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87798 and 87481. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says these services are incidental 
to other services provided on the date in question. 
 
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 codes 
87798 and 87481 are column II codes to column I code 87801; however, 87798 and 87481 were each billed 
with a modifier.  
 
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 procedure codes 87150, 87798 and 87481. Our reviewer says 
that the codes and modifiers at issue are not supported in the medical record. Our reviewer found codes 87481 
and 87798 are not supported as separately identifiable tests; these tests are included in the description of CPT 
code 87801, which is described as, "multiple organisms". The records provided do not support the use of the 59 
modifier in this case. In addition, the medical record does not contain test results supporting culture typing by 
gene analysis was performed for the sample in question; therefore, code 87150 is also not supported in the 
medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87798 and 87481 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87798 and 87481 billed for date of 
service December 13, 2022.
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does 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 the enrollee is a 67-year-old male who was admitted to the acute care hospital with 
shortness of breath and difficulty swallowing and speaking. Imaging showed no mass or other abnormality. 
Neurology suggested possible neuropathy, ALS, or other condition causing his symptoms. The enrollee was 
intubated, placed on vent support, had trach and PEG placements, and was given PPI and heparin. Recent notes describe the enrollee as now tolerating trach trials.  
1. The enrollee appears to be improving with treatment and should only require short-term additional acute care 
services that can safely be provided at the current facility until more appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility.  
2. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility.  
3. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. Completion of 
treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 93313 is echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe 
only.  We find that CPT code 93313 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93313 billed for date of service July 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography, thoracic spine; with contrast material 
(72129). 
 
You asked the Plan to pre-approve a computed tomography, thoracic spine; with contrast material (72129). The 
Plan denied your request. The Plan says that the medical records do not show that the enrollee has had at least a 
six-week trial of conservative treatment which includes medications, physical therapy and/or a home exercise 
program and had a re-evaluation after this conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a computed tomography, thoracic spine; 
with contrast material (72129). Our reviewer says that you need this medical item. Our physician reviewer 
found a computed tomography scan is required to evaluate whether there is significant pathology that would 
preclude placement of the leads. 
 
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 computed tomography, thoracic spine; with contrast material (72129) have 
been met. Therefore, we decided that the Plan has to pre-approve a computed tomography, thoracic spine; with 
contrast material (72129).  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are 
necessary as the enrollee has decreased strength and is declining. The Plan denied your request. The Plan says 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 15, 2022, to July 
26, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 A41.9, described as sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found the enrollee presented with chest pain and shortness of breath. She was found to 
have pneumonia, in the setting of chronic obstructive pulmonary disease and coronary artery disease. There is 
no evidence that the enrollee had systemic organ failure related to her pneumonia.  
 
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 inpatient hospital services provided on July 15, 2022, to July 26, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on August 10, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim to be 
reconsidered for payment, as the services were urgently needed and medically necessary. The Plan denied your 
request. The Plan says the billed services were 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital 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 subsequent hospital care. Our reviewer found the 
provided documentation described a brief history of the enrollee being alert, denying symptoms and was not 
detailed. The documented physical examination was basic and not detailed and revealed lower extremity 
edema/redness. Our reviewer found that the note described a stable enrollee being treated for cellulitis, 
tolerating intravenous antibiotics and fluids without complexities. There was no evidence of medical decision-
making of high complexity on this date. Our physician reviewer found that therefore, the documentation does 
not sufficiently support procedure code 99233. 
 
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 subsequent hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99233) provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
suspension sleeve (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member does not have lymphedema extending onto 
the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652) and suspension sleeve (E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the service is 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you want to see this physician because this physician specializes in small intestinal 
bacterial overgrowth syndrome. The Plan denied your request. The Plan says a network provider can care for 
your medical condition. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 11, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this service should be covered under the 
surgeon's authorization. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 14, 2022. 
 You asked the Plan to pay for laboratory services. You say that you disagree with the denial and request 
reconsideration of payment for the referenced claim. You also say the enrollee requested the testing. The Plan 
denied your request. The Plan says they do not have the information needed to consider these charges. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, laboratory services, was requested solely for screening purposes. The records 
show the provider requested these tests to determine whether medicines that the enrollee is taking are beneficial 
or could increase their risk toward an adverse drug reaction because the enrollee is taking several medications. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided on July 14, 2022.