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

 
We decided that the Plan has to pay for procedure code 99291 billed for September 13, 2022. 
 
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 that payment is not appropriate for the billed code. 
 
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 states that payment for code 99291 is not appropriate; however, further 
explanation is not provided. The Plan has not referenced any binding Medicare rules or supporting 
documentation to show that the code is not payable as billed. Therefore, we decided that the Plan has to pay for 
procedure code 99291 billed for 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99213) provided on June 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service in included 
in the global surgery period for the procedure provided on the same date. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 We looked at the file and Medicare rules. Payment for the requested services (99213) is included in the global 
surgery period for the procedure (20610) provided on the same date of service. Separate payment cannot be 
made for code 99213. 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 the services (99213) provided 
on June 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 72-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that the enrollee needs 
transportation to several appointments. The Plan denied your request. The Plan says the requested number or 
trips exceeds the Plan's limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
72-trip limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service July 27, 
2022, to August 1, 2022. 
 
You asked the Plan to pay for procedure code 99231. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says payment for code 99231 is bundled into payment for 
codes 99232 and 99233. 
 
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 99231 
is a column II code to column I codes 99232 and 99233 with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99231 billed for date of service July 27, 2022, to 
August 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Parathyroidectomy ( 60500, 76536) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Parathyroidectomy. You say that this service is medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 a 
Parathyroidectomy ( 60500, 76536) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing for susceptibility 
to breast or ovarian cancer is not covered for individuals with no personal history of breast, ovarian, fallopian 
tube, primary peritoneal, pancreatic, or prostate cancer. 
 
We looked at the file and Medicare rules. The records show no personal history of breast, ovarian, fallopian 
tube, primary peritoneal, pancreatic, or prostate cancer. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing (81162).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service March 23, 2022, to 
March 27, 2022. 
 
You asked the Plan to pay for code 99233. You say that you have provided medical records to support payment 
of this code. The Plan denied your request. The Plan says the use of code 99233 for dates of service March 23, 
2022, to March 27, 2022, is not supported in the medical record. 
 
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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. 
 
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 code 99233. Our reviewer says that code 99233 is not 
supported in the medical record. Our reviewer found the documentation submitted does not include medical 
records for the billed date of service; therefore, the billed service cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service March 23, 2022, to March 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for outpatient hospital services provided on April 22, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that this service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). 
 
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 has not provided a Medicare rule to substantiate their denial. 
Therefore, we decided that the Plan has to pay for outpatient hospital services provided on April 22, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. 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 Imfinzi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested drug is not FDA-approved 
for the enrollees diagnosis. It is approved in combination with cisplatin and gemcitabine. 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you need this testing to receive the treatment 
you need. The Plan denied your request. The Plan says that this testing is a screening service, and you do not 
have coverage for out-of-network services. 
 
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. Although the Plan states that the requested testing is a screening service, they 
have not provided any documentation of the specific tests requested, such as the initial authorization request, or 
medical records that show your condition and the reasoning the testing was ordered. There also is no 
documentation in the file indicating a specific provider was requested for the testing at issue and that the 
requested provider is out-of-network with the Plan. Without this information, the Plans denial reasoning 
cannot be verified. Therefore, we decided that the Plan has to pre-approve genetic testing.  
 
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 power lift for an electric scooter (E1399). 
 
You asked the Plan to pre-approve a power lift. You say that you were approved for an electric scooter. You 
say that you have weakness on your left side. You also say that you need a power lift. The Plan denied your 
request. The Plan says items for convenience are not covered. 
 
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 a power lift for an electric scooter (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you need this benefit. The Plan denied your request. 
The Plan says the documentation from your provider does not support that you meet the criteria for this extra 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not have one of the eligible 
conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve telehealth services to be provided by an out-of-network 
cardiologist. 
 
You asked the Plan to pre-approve telehealth services to be provided by an out-of-network cardiologist. The 
Plan denied your request. The Plan says there is no coverage for out-of-network telehealth services. 
 
The Plan contract says that there is no coverage for out-of-network telehealth services. 
 
We looked at the file and the Plans rules. The file shows there is no coverage for out-of-network telehealth 
services. Therefore, we decided that the Plan does not have to pre-approve telehealth services to be provided by 
an out-of-network cardiologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diabetic custom molded shoe (A5501) and diabetics 
only, multiple density insert (A5514) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that you did not know the supplier 
was out of network, but the shoes are already made and ready for pick up upon approval. You cannot wait any 
longer to start the process again with an in-network provider. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a diabetic custom molded shoe (A5501) and diabetics only, multiple density insert (A5514) to be provided by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you would really benefit from having a 
CGM, so you hope your insurance will approve the request. The Plan denied your request. The Plan says you 
do not require insulin three or more times daily. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided on September 20, 2022. 
 
You asked the Plan to reimburse you for psychotherapy. The Plan denied your request. The Plan says that the 
Plan is missing proof of payment to the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of psychotherapy have been met. The file 
does not contain proof of payment to the provider. Therefore, we decided that the Plan does not have to 
reimburse you for psychotherapy provided on September 20, 2022.
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 May 2, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the requested procedure code is valid and billable. You 
also say that the requested wig is not cosmetic. The Plan denied your request. The Plan says a wig is not 
considered durable medical equipment as it is not reasonable and necessary for treatment of illness or injury, it 
is not used to serve a medical purpose, and it is primarily for convenience or comfort. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99214 billed for date of service September 26, 2022. 
 
You asked the Plan to pay for code 99214. You say that this code was billed correctly. The Plan denied your 
request. The Plan says code 99214 is not supported by the medical record. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 code 99214. Our reviewer says that code 99214 is not 
supported by the medical records. Our reviewer found the enrollee was a then 73-year-old male with a history 
of hypertension and hyperlipidemia who underwent an office evaluation on September 26, 2022. The 
documentation received did not support a moderate level of medical decision making and time was not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service September 26, 2022.