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

 
We decided that the Plan has to pre-approve wound care and wound debridement services. 
 
You asked the Plan to pre-approve wound care and wound debridement services. You say that these services 
are medically necessary and reasonable. The Plan denied your request. The Plan says that the requested 
services requested cannot be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve wound care and wound debridement 
services. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the records provided document multiple wounds of the 
left hip, left shoulder, left foot, left upper and lower back and sacrum with exudate, abnormal granulation 
tissue, slough and necrotic tissue for which wound care and/or wound debridement services appear to be 
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 wound care and wound debridement services have been met. Therefore, we 
decided that the Plan has to pre-approve wound care and wound debridement services.  
 
Please note: payment for these services may need to be sought from the Skilled Nursing Facility under 
arrangements for any services provided during the span of a Part A admission/stay. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, any joint of lower extremity; without contrast 
material right and left (73721 x 2). 
 
You asked the Plan to pre-approve the MRIs. You say that the MRIs are medically necessary. The Plan denied 
your request. The Plan says the MRIs are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRIs. Our physician reviewer 
found there is no specific clinical rationale for knee MRIs. The review has determined that the MRIs are not 
medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the MRIs have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the MRI, any joint of lower extremity; without contrast 
material right and left (73721 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 21, 2022. 
 
You asked the Plan to pay for physician services. You say that the enrollee informed you they were covered 
under Medicare. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physician services 
provided on March 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on May 24, 2021, as 
billed. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 home health services as billed. Our 
reviewer says that the documentation does not support the Patient-Driven Grouping Model (PDGM) 30-day 
payment period Health Insurance Prospective Payment System (HIPPS) code rate of 3BC21. Our physician 
reviewer found the provided records in this case document skilled nursing and occupational therapy visit notes 
and discharge summaries, but the provided records do not include a Plan of Care, an Outcome and Assessment 
Information Set (OASIS) or an Occupational Therapy Initial Evaluation to support the services rendered. 
Therefore, the services are not payable as billed. 
 
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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided on May 24, 2021, as billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for May 30, 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 procedure code 99233 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 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 these services. Our reviewer says that procedure code 99233 is not supported. Our reviewer found that the enrollee was evaluated on May 30, 2022 which was day three in 
the hospital. The submitted records do not support that there was a comprehensive history, comprehensive 
examination, or medical decision making of high complexity. Procedure code 99233 is not supported by the 
submitted records. 
 
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 99233 billed for May 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Auryxia. 
 
You asked the Plan to pre-approve Auryxia. You say that the enrollee is currently tolerating a sample trial of 
this drug. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Auryxia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services billed on August 16, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid principal 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that manifestation diagnosis codes are never 
permitted to be used as first listed or principal diagnosis codes.  
 
We looked at the file and Medicare rules. You billed this code with principal diagnosis code R18.0, described 
as malignant ascites which is a manifestation code and cannot be used as a primary diagnosis code. Based on 
this information, we decided that Medicare rules for coverage of radiology services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for radiological services billed on August 16, 
2022.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 64636, 64635, and J3301. 
We decided that the Plan does not have to pay for the services described by procedure code J3490.  
 
You asked the Plan to pay for codes 64636, 64635, J3301, and J3490 provided on September 7, 2022.. You say 
that you disagree with the Plan's denial. The Plan says that code J3490 is included in the global period. 
 
We decided that the Plan has to pay for the services described by procedure codes 64636, 64635, and 
J3301.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 64636, 64635, and J3301.  
 
We also decided that the Plan does not have to pay for the services described by procedure code J3490. 
 
The Plan follows 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 J3490 is not supported in the medical record. Specifically, this code was billed within 
the global surgery period of a surgery procedure. Without an appropriate modifier, this code is not payable as 
billed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code J3490 have not been met. Therefore, we decided that the 
Plan does not have to pay for the services described by procedure code J3490. 
 
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 pre-approve ultrasound-guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that the requested services are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request 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 US-IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that daily simple simulations and/or IGRT are a technology for which need has not been established by 
published data or supported by consensus guidelines (many of which recommend against treatment with these 
devices in general). Daily IGRT would not be furnished in accordance with accepted standards of medical 
practice. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound-guided radiation therapy (US-IGRT).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided on 
August 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says there were 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90834) provided on August 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging of retina (92134), injection of drug into eye 
(67028), and bevacizumab (C9257) provided on June 7, 2022, to August 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the physician services. You say that your plan has been honoring payment for 
this treatment for many years. You say that you were never advised that this benefit would be discontinued. 
You say that it will be a difficult hardship to find a new retina specialist as you would be referred to a provider 
250 to 300 miles away. The Plan denied your request. The Plan says services received out-of-network are not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan confirmed there were network 
providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-
approve the item/service at issue. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the imaging of retina (92134), 
injection of drug into eye (67028), and bevacizumab (C9257) provided on June 7, 2022, to August 16, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and incision procedures on the dentoalveolar 
structures provided on January 3, 2023. 
 
You asked the Plan to pay for an office visit and incision procedures on the dentoalveolar structures. You say 
that the services should be covered under your medical benefits. The Plan denied your request. The Plan says 
the member did not contact the Plan prior to the date of service to verify benefits and provider eligibility. The 
Plan will maintain its initial determination to not provide payment for non-covered and excluded services. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an office 
visit and incision procedures on the dentoalveolar structures provided on January 3, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 87481, 87563, 87640, 87653 and 87798. We decided 
that the Plan does not have to pay for procedure code 87491.  
 
You asked the Plan to pay for laboratory services (87481, 87491, 87563, 87640, 87653 and 87798) billed for 
date of service August 24, 2022. You say that these services are supported as billed. The Plan says that the 
medical records do not support the reporting of these services. 
 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87481, 87563, 87640, 87653 and 87798. 
Our reviewer says that the medical records support the reporting of some of the services at issue. Our physician 
reviewer found the medical records do support codes 87481, 87563, 87640, 87653 and 87798, as the results and 
order for these services are present in the medical labs. However, the medical records do not support code 
87491, as there are no lab results for this organism, and this service is not on the lab request. 
 
We decided that the Plan has to pay for procedure codes 87481, 87563, 87640, 87653 and 87798.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87563, 87640, 87653 and 87798 have been met. 
Therefore, we decided that the Plan has to pay for procedure codes 87481, 87563, 87640, 87653 and 87798.  
 
We also decided that the Plan does not have to pay for procedure code 87491. 
 
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 87491 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87491. 
 
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 pay for procedure code B4189 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code B4189. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code B4189 is 1. The MAI value for this code is 2. You billed 7 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code B4189 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code B4189 billed for date of service June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on August 18, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not covered by the 
MolDX program or was not reported according to MolDX guidelines. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Therefore, we decided that the Plan does not have to 
pay for DecisionDx-SCC testing (0315U) provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.