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

 
We decided that the Plan does not have to pay for procedure code 99223 billed for December 28, 2021. 
 
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 code 99223 is 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 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 these services. Our reviewer says that procedure code 99223 is not supported. Our reviewer found the records do not support that the enrollee's presenting problems were of 
high severity or that the medical decision making was of high complexity. The billing of code 99223 is not 
supported by the submitted documentation. 
 
We looked at this coder's review, the file, and Medicare rules. 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 code 99223 billed for December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit rendered on April 20, 2022. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says this was provided by an opt-out physician. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit rendered on April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that you disagree with the 
denial. The Plan denied your request. The Plan says you do not meet criteria for approval of the CGM and 
supplies. 
 
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 Freestyle Libre CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
(K0856) and accessories (E0955, E1002, E1028, E2310, E2361, E2607). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with a single power option and accessories. 
You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
need the requested power option. 
 The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with a single power 
option is covered if the beneficiary requires a drive control interface other than a hand or chin-operated 
standard proportional joystick or the beneficiary meets coverage criteria for a power tilt or a power recline 
seating system and the system is being used on the wheelchair. If the power wheelchair base is not covered, 
then related accessories will be denied. 
 
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 group 3 power wheelchair with a 
single power option and accessories. Our reviewer says that the requested power wheelchair is not medically 
necessary. Our physician reviewer found the records do not document that the enrollee is at a high risk for skin 
breakdown or that the enrollee has pressure ulcers. The enrollee does not use catheterization and there is no 
documentation of increased tone or spasticity. The records do not show that the enrollee requires a drive 
control interface. 
 
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 group 3 power wheelchair with a single power option and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with a single power option (K0856) and accessories (E0955, E1002, E1028, E2310, E2361, E2607).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dobutamine hydrochloride (J1250) provided on July 7, 
2022. 
 
You asked the Plan to pay for the dobutamine hydrochloride. You say that the enrollee billed as necessary. The 
Plan denied your request. The Plan says the drug is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the dobutamine hydrochloride. Our reviewer 
says that the dobutamine hydrochloride was not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation indicates the enrollee underwent a dobutamine stress 
echocardiogram. The reviewer found that dobutamine stress echocardiography is frequently used to assess 
myocardial viability; however, the inotropic response to adrenergic stimulation may be reduced in patients receiving a beta-blocker. The documentation indicates that a beta-blocker was provided. Therefore, the 
reviewer found that the dobutamine hydrochloride was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the dobutamine hydrochloride have not been met. Therefore, we decided that 
the Plan does not have to pay for the dobutamine hydrochloride (J1250) provided on July 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from August 17, 
2022, to September 15, 2022. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay was not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not qualify for SNF coverage. The enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs could, as a practical matter, be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from August 17, 2022, to September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a temporary implantable nitinol device 
(iTIND). 
 
You asked the Plan to pre-approve placement of an iTIND. 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 placement of an iTIND. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found temporary implantable nitinol device (iTIND) is not medically reasonable and 
necessary in this case. Further studies are needed to evaluate the durability of iTIND outcomes over a longer 
follow-up, to better define the indications of this approach, and to demonstrate the advantages of second-
generation device over the first device. ITind is not recommended in the most recent AUA Guidelines 
regarding treatment of benign prostatic hyperplasia (BPH). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an iTIND have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a temporary implantable nitinol device (iTIND).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (procedure code 99239) 
rendered on August 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 according to Medicare, CPT code 
99239 can be used for hospital discharge day management that takes more than 30 minutes. In this case, the 
documentation available for review does not support a hospital discharge day management that took more than 
30 minutes occurred. The documentation from 8/11/2022 includes an encounter by the medical provider that is not clear to be a discharge summary. 
 
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 hospital discharge day management (procedure code 99239) rendered on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on August 2, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on August 2, 2022. The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99223 provided on August 2, 2022. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on August 2, 2022. Our reviewer found the enrollee 
was admitted for a left knee arthroplasty. The documentation indicates that code 99223 provided on August 2, 
2022, was not supported in the medical records. The medical records supported a comprehensive history and a 
comprehensive examination but did not support medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on August 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found there is no information from the 
provider documenting outcomes and date of the last viscosupplementation. The review has determined that the 
documentation does not support that Euflexxa is medically reasonable or necessary for the enrollee. The 
documentation does not support that Euflexxa is safe and effective 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36246 and 75710 rendered on September 
29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is part of the primary procedure and not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36246: 
 Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case the medical records 
do not include sufficient documentation to validate that 36246-59 or 75710-59 were performed as distinct 
separate services, unrelated to the primary procedure; therefore, the use of Modifier 59 is not appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36246 and 75710 rendered on September 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says unless there is a pathological fracture, a trial of Zoledronic acid is required before Prolia 
can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record shows no evidence of pathological fracture 
or a trial of the plan's preferred drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, total electric (head, foot, and height 
adjustments), with any type of side rails, with mattress (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you are unable to get up from the 
bed by yourself and it would be very difficult for any caregiver to get you out of bed without the requested bed. 
The Plan denied your request. The Plan says total electric beds are denied as not reasonable and necessary 
because the height adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, total 
electric (head, foot, and height adjustments), with any type of side rails, with mattress (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air purifier (E1399). 
 
You asked the Plan to pre-approve an air purifier. You say that you disagree with the denial. The Plan denied 
your request. The Plan says an air purifier is not covered under your plan benefits because is not medical in 
nature and is regularly and primarily used by persons who do not have a specific medical need for them. This 
means it is not accepted as standard medical treatment. 
 
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 an air purifier (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature (E0470) and a humidifier (E0562). 
 
You asked the Plan to pre-approve a respiratory assist device and humidifier. You say that you disagree with 
the denial and request consideration. The Plan denied your request. The Plan says this denial is upheld due to 
lack of medical necessity. There is no documentation if steady use of the positive airway pressure machine for 
an average of four hours or more per 24 hours for at least 70 percent of nights and no documentation of a face-
to-face visit with the provider after the first three months of treatment that show symptoms have improved. 
 
The Plan must follow Medicare rules. The rules say that a respiratory assist device is covered for those 
beneficiaries with OSA who meet criteria. 
 
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 respiratory assist device and 
humidifier. Our reviewer says that the service is not reasonable and necessary. Our physician reviewer found 
continued coverage of a BiPAP device is considered not medically necessary. You have obstructive sleep 
apnea. The only records provided are a compliance report that shows only 1 day of use for more than 4 hours 
over a period of 3 months. This does not meet minimum Medicare criteria and is not enough to be effective. In 
addition, there is no documentation of a follow-up clinical visit.  The denial is upheld. 
 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 respiratory assist device and humidifier have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature (E0470) and a humidifier (E0562).