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

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show a failure of standard wound therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered for certain 
indications. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has a covered indication for this therapy. The medical documentation notes that the 
diabetic patient has a right first ray wound that has had multiple active infections. A toe amputation was 
performed. A bone scan confirmed osteomyelitis of the right great toe. The patient has undergone routine 
debridement with dressing changes and offloading of the ulcerative area. They have also undergone negative 
pressure wound therapy; however, the wound remains very deep. The clinical notes advise that the wound is 
down to muscle and adipose tissue. This patients first ray diabetic wound meets the coverage guidelines in that 
the wound is a diabetic wound, the patient has type II diabetes which is considered a Wagner grade 3, and has 
failed conservative treatments including routine debridement, offloading, oral antibiotics, and negative pressure 
wound therapy.  
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 services have been met. Therefore, we decided that the Plan has to pre-
approve hyperbaric oxygen therapy.  
 
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 wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 (A9282).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for L2-L3 decompression and 
fusion. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure is helpful for treatment. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan approved the L3-4 decompression and fusion with inpatient stay. However, there is no 
specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is 
a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate 
for this enrollees medical condition as discussed above. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested bone marrow aspiration for the L3-4 decompression and fusion, in this case, is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for L2-L3 decompression and fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on October 17, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the primary diagnosis code 
billed (I43) is a manifestation diagnosis code and cannot be billed as the primary diagnosis. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99233) provided on October 
17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Novolog. 
 
You asked the Plan to pre-approve a tiering exception for Novolog. You say that the exception is needed. The 
Plan denied your request. The Plan says the drug does not qualify for tiering exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tiering exception for Novolog have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tiering exception for Novolog.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail (E0241) and raided toilet seat 
(E0241). 
 
You asked the Plan to pre-approve the bathtub wall rail and a raised toilet seat. You say that the enrollee needs 
these items to be covered in order to safely use the bathroom. The Plan denied your request. The Plan says 
these items are not covered by Medicare or the Plan. 
 
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 bathtub wall rail (E0241) and raided toilet seat (E0241).
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 a LTACH admission is medically 
appropriate for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has uncertain value. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure. There remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that you have bacteria build up in your mouth, 
and you need a biopsy. You have severe shooting pain, and you need to see a dentist as soon as possible. The 
Plan denied your request. The Plan says dental services from an out-of-network provider are not covered by 
your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s) laboratory test 
(82306) provided on October 6, 2022. 
 
You asked the Plan to pay for Vitamin D laboratory service. You say that the requested test was not performed 
on October 6, 2022, therefore, you are not responsible for the charges. You also say this was a mistake by your 
physician assistant. The Plan denied your request. The Plan says prior to services being rendered on October 6, 
2022, you were presented with, and signed, a financial waiver form stating that you elected not to call the plan 
for a coverage decision. You agreed in writing, that you understood that you may be responsible for the full 
cost of the services. The requested test is not a covered benefit with Medicare or the Plan. The claim processed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We looked at the file and Medicare rules. The LCA lists ICD-10-CM codes that support the medical necessity 
of CPT code 82306. The records show your diagnosis code is L65.0. This diagnosis code is not listed as criteria 
for coverage of the requested Vitamin D Assay test. Based on this information, we decided that Medicare rules 
for coverage of Vitamin D laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for Vitamin D; 25 hydroxy, includes fraction(s) laboratory test (82306) provided on October 6, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 3, 2022, to April 8, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG and principal diagnosis code was not 
supported. 
 
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 DRG 193. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that documentation does not indicate that the treatment ordered by the treating medical providers supported a 
diagnosis code of J18.9 (Pneumonia unspecified organism) and J96.21(Acute and chronic respiratory failure 
with hypoxia). In this case, the documentation does not consistently and completely support the assigned 
principal and secondary diagnosis codes with DRG. The replacement of DRG is upheld as it is supported by the 
medical documentation.  
 
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 to the enrollee from April 3, 2022, to April 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 85025, 85610, 85060, 85097, 88184, 88185, 88305, 
88311, 88313, 88341, 88342, 88365, 88160, 77012, 38222, 94762, J2250, and J3010 provided on September 9, 
2022. 
 
You asked the Plan to pay for codes 85025, 85610, 85060, 85097, 88184, 88185, 88305, 88311, 88313, 88341, 
88342, 88365, 88160, 77012, 38222, 94762, J2250, and J3010. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 85025, 85610, 85060, 85097, 88184, 88185, 88305, 88311, 88313, 88341, 88342, 
88365, 88160, 77012, 38222, 94762, J2250, and J3010 are not supported in the medical record. Specifically, 
per the Integrated Outpatient Code Editor (OCE) specifications, CPT code 85060 denied as a non-allowed 
service for Outpatient Prospective Payment System (OPPS). Services with a status indicator of B are not 
payable. The OCE edit error must be corrected for the remaining lines to be processed. The claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of codes 85025, 
85610, 85060, 85097, 88184, 88185, 88305, 88311, 88313, 88341, 88342, 88365, 88160, 77012, 38222, 94762, 
J2250, and J3010 have not been met. Therefore, we decided that the Plan does not have to pay for codes 85025, 
85610, 85060, 85097, 88184, 88185, 88305, 88311, 88313, 88341, 88342, 88365, 88160, 77012, 38222, 94762, 
J2250, and J3010 provided on September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral (64628). 
 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing the wrongful denial 
for Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The 
Plan denied your request. The Plan says the Intracept procedure is considered unproven as it clinical value and 
effectiveness have not been demonstrated in the peer-reviewed literature. More research is needed to show 
safety and efficacy of the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral bodies with 
imaging guidance, lumbar or sacral (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means code 
99153 is a stand-alone code that describe the technical component (i.e., staff and equipment costs) of selected 
diagnostic tests for which there is an associated code that describes the professional component of the 
diagnostic tests only. Code 99053 is a diagnostic test and therefore, does not have a related professional 
code. Modifiers 26 and TC cannot be used with these codes. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99153 billed for date of service June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and office visit (99205, 99214) with a 
urology oncologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and an office visit. You say that the enrollee would like to see 
the requested provider as he is the leading doctor specializing in urologic oncology and feels that he would be 
the best in treating his diagnosis. The enrollee also expressed that UCSF is closer to his home and he feels safer 
and more comfortable driving to San Francisco as opposed to dealing with Los Angeles traffic. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. 
There are in-network providers available for this service. 
 
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 consultation and office visit (99205, 99214) with a urology oncologist to be provided by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
March 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
March 2, 2022.