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

 
We decided that the Plan does not have to pay for the hyperbaric oxygen therapy (G0277) provided from 
September 15, 2022, to September 24, 2022. 
 
You asked the Plan to pay for the hyperbaric oxygen therapy (G0277). You say that the provided hyperbaric 
oxygen therapy (G0277) was medically necessary. The Plan denied your request. The Plan says the enrollee did 
not meet criteria for the provided hyperbaric oxygen therapy (G0277). 
 
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 hyperbaric oxygen therapy (G0277). Our 
reviewer says that the enrollee did not meet criteria for the provided hyperbaric oxygen therapy (G0277). Our 
physician reviewer found the review indicates that the enrollee had Hyperbaric oxygen under pressure, full 
body chamber, per 30-minute interval due to significant diagnosis of sudden unspecified sensorineural hearing 
loss. The review has determined that the enrollee did not meet the NCD criteria for the provided hyperbaric 
oxygen therapy (G0277). 
 
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 hyperbaric oxygen therapy (G0277) have not been met. Therefore, we 
decided that the Plan does not have to pay for the hyperbaric oxygen therapy (G0277) provided from 
September 15, 2022, to September 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the medication is 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. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is truly the only solution for the enrollee. 
The Plan denied your request. The Plan says the procedure 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 heavy-duty, patient 
weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are not able to walk around the house 
and cook for yourself. You need the mobility device to be able to get around. The Plan denied your request. 
The Plan says your request is not medically necessary because your records show your home does not have 
adequate access due to the flight of entry stairs, and lack of room within the apartment. You are described as 
modified independent with activities of daily living in the home and do not have limited mobility-related 
activities of daily living. You were assessed to require a 4-wheeled rolling walker. 
 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The medical 
records sent by your provider indicates you were evaluated by a physical therapist on January 24, 2023, for 
candidacy for a scooter, which was considered not medically necessary. You are requesting a scooter that can 
be put inside a car and transported up and down a flight of stairs. You live in a second-floor apartment without 
elevator access. You are described as having a wheelchair inaccessible apartment. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds (K0801).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says your request for admission to an IRF is denied 
as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99292 billed for date of service August 13, 2022. 
 
You asked the Plan to pay for code 99292. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code 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 99291 is used to report the first 30-74 minutes of critical care on a given date. Code 
99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.  In 
this case, you billed both codes 99291 (which was paid), and 99292.  However, the medical records clearly 
state that only 73 minutes were spent on critical care on the date of service in question.  Because payment for 
code 99291 already includes payment for up to 74 minutes of critical care, additional blocks of time are not 
payable in this instance. 
 Based on this information, we decided that Medicare rules for coverage of code 99292 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99292 billed for date of service August 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from June 27, 2022, to June 28, 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 documents do not support this level of care. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was admitted to the 
hospital on 06/26/2022 with a diagnosis of fever and pneumonia. The documentation doesn't include a 
comprehensive history and medical decision making of high complexity for the dates in question. 
 
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 subsequent hospital care (procedure code 99233) rendered from June 27, 2022, to June 28, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. 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. 
 
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 Gelsyn-3. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no rational reason to use this agent 
over the preferred agents before a trial of the preferred agents. The request for Gelsyn-3 is not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (00820) provided on February 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a duplicate 
charge. 
 
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 argues that this is a duplicate charge. However, the Plan has not 
provided documentation showing that code 00820 was billed and paid on a separate claim. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
anesthesia services (00820) provided on February 9, 2021.  
 
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 codes 99211 and 80307 billed for date of service October 25, 
2022. 
 
You asked the Plan to pay for codes 99211 and 80307. You say that these services were billed correctly and 
should be covered. The Plan denied your request. The Plan says you billed with an incorrect diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that a combination code is a single code used to 
classify two diagnoses.  The combination code should be assigned when it fully identifies the diagnostic 
conditions involved.  In this case, you billed these services with diagnosis codes M17.11 (unilateral primary 
osteoarthritis, right knee), and M17.12 (unilateral primary osteoarthritis, left knee).  Instead of billing two 
separate unilateral diagnoses, you should have billed the combined diagnosis code of M17.0, which represents 
bilateral primary osteoarthritis of the knee. This would encompass both the right and left diagnoses. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 99211 and 80307 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 99211 and 80307 billed for date of service October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation vest (E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation vest. You say that this device 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 high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation vest (E0483).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425, A0382) provided on 
June 21, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says the payment for these services is included in 
the facility payment to the inpatient hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status one facility from June 19, 2022, to June 24, 2022. This means that the services at issue are 
considered patient transportation and are paid to the facility. Therefore, we decided that the Plan does not have 
to pay for ambulance services (A0429, A0425, A0382) provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a suprascapular nerve block (code 64418) provided on June 11, 2021. 
 
You asked the Plan to pay for the suprascapular nerve block. You say that the suprascapular nerve block was 
medically necessary. The Plan denied your request. The Plan says that experimental or investigational services 
are not covered. 
 
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. Specifically, the Plan has not provided a review for medical necessary or a rule 
to support their denial. Therefore, we decided that the Plan has to pay for a suprascapular nerve block 
(code 64418) provided on June 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 17, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81319, and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
should be paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT code 
on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 17, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81319, and 81294.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health services to be provided by an  
out-of-network provider. 
 
You asked the Plan to pre-approve behavioral health services to be provided by an out-of-network provider. 
The Plan denied your request. The Plan says the services can be provided by in-network providers. 
 
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 behavioral 
health services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detachable armrests (code E0973) billed for date of 
service June 8, 2022. 
 
You asked the Plan to pay for code E0973. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says there is no proof of delivery for these armrests. 
 
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 not contain a valid proof of delivery for these armrests. The delivery receipt only lists codes 
E0971, E2601, K0003, and E2611.  There is no evidence that armrests billed with code E0973 were including 
in the shipment sent to the member. Therefore, we decided that the Plan does not have to pay for the detachable 
armrests (code E0973) billed for date of service June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home blood glucose monitor billed with code E0607 for 
October 5, 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 the services were not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that code E0607 must be billed with modifier -KX or 
-KS. 
 
We looked at the file and Medicare rules. The file shows that code E0607 was not billed with the required -KX 
or -KS modifier. 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 the home blood glucose monitor 
billed with code E0607 for October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 30-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation to dialysis appointments. The Plan denied your request. The Plan says you have exhausted your 
transportation benefit. 
 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 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have 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 
30-trip limit.