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

 
We decided that the Plan does not have to pay for the wound care supplies (A6197) provided on October 12, 
2021. 
 
You asked the Plan to pay for the wound care supplies. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says no separate payment is made 
for this service under Medicare rules. 
 
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 A6197 is alginate or other fiber gelling dressing, wound 
cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing. 
 
We looked at the file and Medicare rules. Specifically, this code has a status indicator of "P" under the 
Physician Fee Schedule. Payment for these codes is always included in payment for other codes. Based on this 
information, we decided that Medicare rules for coverage of the wound care supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound care supplies (A6197) provided on 
October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel testing provided on August 31, 2020. 
You asked the Plan to pay for the testing services. You say that the clinical value of the testing benefits the 
enrollee. The Plan denied your request. The Plan says the test does not meet reasonable and necessary 
requirements. 
 
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. Respiratory panels of 6 or more pathogens are non-covered. They do 
not meet Medicares reasonable and necessary criteria. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory panel testing provided on August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from September 18, 
2021, to September 29, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. The Plan denied your request. The Plan says the 
enrollee was already under Hospice care; this admission should be covered under Hospice and Fee for Service 
(FFS) Medicare instead. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 18, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services provided from September 18, 2021, to September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37224 billed for date of service September 
29, 2020. 
 
You asked the Plan to pay for procedure code 37224. You did not provide an argument for coverage. The Plan 
denied your request. The Plan says this code 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 37224 is revascularization, endovascular, open or 
percutaneous, femoral popliteal artery(s), unilateral: with transluminal angioplasty. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 37224. Our reviewer says that procedure 
code 37224 is not supported by the medical record. Our reviewer found the operative report does not include 
documentation of revascularization of the femoral popliteal artery.  The operative report describes angioplasty in the popliteal and tibioperoneal trunk, which has been reported and approved.  This procedure (37224) was 
not documented in operative report, and therefore 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 procedure code 37224 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 37224 billed for date of service September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a drug regimen of Gemcitabine, Cisplatin, and 
Durvalumab. 
 
You asked the Plan to pre-approve the requested drug regimen. You say that these drugs are medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this mix of 
drugs is not supported in the National Comprehensive Cancer Network guidelines for the enrollee's cancer. 
 
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 the requested drug regimen. Our 
reviewer says that the requested drug regiment is not medically reasonable and necessary for the enrollee's 
condition. Our physician reviewer found the enrollee has been diagnosed with metastatic cholangiocarcinoma. 
In this case, the requested use of Gemcitabine, Cisplatin, and Durvalumab is not FDA-approved for the 
enrollees diagnosis. In addition, the use of the requested drugs is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal.  Currently, this drug regimen is the TOPAZ-1 trial which appears in abstract form only. Until this is published 
in a peer-reviewed journal, it will remain experimental/investigational. 
 
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 requested drug regimen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a drug regimen of Gemcitabine, Cisplatin, and Durvalumab.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 
(A0427, A0425) provided on September 30, 2021. 
 
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say 
that the enrollee was transported to the hospital from the skilled nursing facility for emergent care. The Plan 
denied your request. The Plan says that ambulance services are covered in the member's skilled nursing facility 
consolidated billing and is not allowed separately. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance service, advanced life support, 
emergency transport, level 1. Our reviewer says that the ambulance transport was medically necessary. Our 
physician reviewer found that the record indicates that the enrollee resides at the subacute nursing facility and 
was transported to the emergency department due to dyspnea and tachycardia. A prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health in such a 
case. The elements of the coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1 have 
been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, 
emergency transport, level 1 (A0427, A0425) provided on September 30, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and mattress. 
 
You asked the Plan to pre-approve the total electric hospital bed and mattress. You say that these items are 
medically necessary. The Plan denied your request. The Plan says the total electric hospital bed is non-covered 
and the record shows and the enrollee already has a group 2 support surface (mattress). 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. The mattress is considered a group 2 support surface and the record shows the enrollee 
has a group 2 support surface for the same purpose. Therefore, we decided that the Plan does not have to pre-
approve a total electric hospital bed (E0265) and mattress.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for surgical management of recurrent volvulus. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 the shingles vaccine provided on October 29, 2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that the doctor recommended the shingles 
vaccination, and you want to know why the Plan does not cover standard prevention. The Plan denied your 
request. The Plan says the shingles vaccine is not listed as a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on October 29, 
2021.  
 
  Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0202U) provided on June 18, 2021. 
 
You asked the Plan to pay for code 0202U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 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 looked at the file and Medicare rules. Medicare says that code 0202U is not covered. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (0202U) provided on June 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PDN services (CPT code S9123). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services of a private duty nurse or other private duty attendant are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Specifically, we 
find that the services at issue in this case are considered custodial in nature. Furthermore, CPT code S9123 has 
a status code of I, which is not valid for Medicare purposes. Medicare uses another code for reporting of and 
payment for these services. Therefore, we decided that the Plan does not have to pre-approve the PDN services 
(CPT code S9123).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion/specialty drug administration (CPT 
code(s): 99601 and 99602). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. CPT code(s): 99601 and 99602, 
have a status code of "I" and are not covered by Medicare. Medicare guidance says status code I Not valid 
for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Therefore, 
we decided that the Plan does not have to pre-approve home infusion/specialty drug administration (CPT 
code(s): 99601 and 99602).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories (K0860, 
K0040, E1002, K0108). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with accessories. You say that the group 3 
power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with accessories (K0860, K0040, E1002, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor 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 (K0554).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supervision of a nursing facility patient (99379) provided 
on August 1, 2021. 
 
You asked the Plan to pay for the supervision of a nursing facility patient (99379). You say that the physician 
provided medically necessary services and the services rendered meet standards of healthcare. You say that the 
claim should be processed for payment. The Plan denied your request. The Plan says bundled services are not 
eligible for separate reimbursement. 
 
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 99379 is supervision of a nursing facility patient (patient 
not present) requiring complex and multidisciplinary care modalities involving regular development and/or 
revision of care plans by that individual, review of subsequent reports of patient status, review of related 
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care 
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) 
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment 
plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, CPT code 99379 has a status 
indicator of B. This means that CPT code 99379 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the supervision of a nursing facility patient 
(99379) have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a 
nursing facility patient (99379) provided on August 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 8.9 routine transportation miles. 
 
You asked the Plan to pre-approve additional routine transportation miles. You say that you are requesting an 
additional 8.9 routine transportation miles. The Plan denied your request. The Plan says this request exceeds 
your maximum 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.  
 We looked at your request, the records in the case file, and the rules. Your 2022 EOC states up to sixty (60) 
one-way trips, combined in and out-of-network, are covered each year (limited to ground transportation only). 
Each one-way trip must not exceed 75 miles of driving distance. A trip is one-way transportation; a round trip 
is two (2) trips. Therefore, we decided that the Plan does not have to pre-approve additional 8.9 routine 
transportation miles.