Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided on July 
3, 2023. 
 
You asked the Plan to pay for PET scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this code was not billed with an acceptable diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that a PET scan is not covered for diagnosis code 
C34.90.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a 
positron emission tomography (PET) scan provided on July 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), and tests (83036, 82274, 82962) 
provided on July 25, 2023. 
 
You asked the Plan to pay for the office visit (99204), and tests (83036, 82274, 82962). You say that the 
services were medically necessary. 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 the office visit (99204), 
and tests (83036, 82274, 82962) provided on July 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23430 rendered on September 7, 2023. 
 
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 procedure code 23430-59-RT is considered inclusive to CPT 23472-RT. 
 
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 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 documentation does not 
support CPT 23430: tenodesis of long tendon of biceps as a separate and distinct procedure from CPT 23472: 
arthroplasty, glenohumeral joint, total shoulder (glenoid and proximal humeral replacement (e.g., total 
shoulder)). The enrollee was being treated for proximal humerus malunion, avascular necrosis humeral head, 
painful hardware, and biceps tendinitis. The enrollee underwent a right shoulder removal of hardware plate and 
screws, reverse total shoulder arthroplasty, and biceps tendinitis on 9/7/23. The procedure details site long head 
of the biceps tendon was identified in zone 2 of the bicipital tunnel and its constraining sheath was opened 
revealing synovitis and debris. The tendon was tenotomized and tenodesed to the proximal margin of the 
pectoralis major tendon with a #2 Orthocord in a locking figure of eight configuration. However, the tenodesis 
was performed in conjunction with the overall reverse total shoulder arthroplasty. The tenodesis was performed 
to allow for/as a part of the reverse total shoulder arthroplasty. 
 
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 procedure code 23430 rendered on September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97597 billed for date of service June 8, 2023. You asked the Plan to pay for the billed service. You say that the treatment was more aggressive than home 
therapy. The Plan denied your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that payment for all items is included in the HH PPS payment the 
primary HHA receives. Based on this information, we decided that Medicare rules for coverage of the billed 
service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97597 
billed for date of service June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on February 21, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that the OIVIT services should be paid as billed 
because they are supported in the medical record. The Plan denied your request. The Plan says the OIVIT 
services are denied because they are not supported in the medical record and there is a more appropriate code 
for the services billed. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve InnovaMatrix skin substitute (A2001). 
 
You asked the Plan to pre-approve InnovaMatrix. 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 experimental/investigational. 
 
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 InnovaMatrix. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that it appears that the InnovaMatrix advanced skin substitute dressing is not needed at this time 
as the enrollee's ulcer is healing/reducing in size.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of InnovaMatrix have not been met. Therefore, we decided that the Plan does not 
have to pre-approve InnovaMatrix skin substitute (A2001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 05, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this service is supported in the 
records proving medical necessity. 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 subsequent nursing 
facility care provided on May 05, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from September 9, 
2023, through September 10, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs 
provided from September 9, 2023, through September 10, 2023.  
 
Benefits for the medication 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the leg (73700). 
 
You asked the Plan to pre-approve a CT scan of the leg. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the leg. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the record indicates that the 
enrollee is scheduled for total knee arthroplasty and the requested test is being performed for computer assisted 
navigation purposes. The provided records do not indicate the medical necessity or reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 a CT scan of the leg have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the leg (73700).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 27, 2023, billed with 
procedure code 99309. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of 
service code. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. We find that this facility claim was billed with an inappropriate place 
of service. Based on this information, we decided that Medicare rules for coverage of the practitioner services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on April 27, 2023, billed with procedure code 99309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation (93298) provided on June 
30, 2023. 
 
You asked the Plan to pay for the interrogation device evaluation (93298). You say that the service was 
medically necessary. 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 the interrogation device 
evaluation (93298) provided on June 30, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve byooviz (Q5124). 
 You asked the Plan to pre-approve byooviz. You say that the patient has already had one injection of byooviz 
on November 21, 2023. The Plan denied your request. The Plan says the documentation provided does not 
include chart notes showing a contraindication, intolerance, or failure of bevacizumab. 
 
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 byooviz. Our reviewer says that the 
enrollee does not meet the criteria for coverage of byooviz. Our physician reviewer found the Plan requires a 
trial of bevacizumab before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug. Our reviewer also found that there is no documentation provided indicating that the 
Plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of byooviz have not been met. Therefore, we decided that the Plan does not have 
to pre-approve byooviz (Q5124).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and does not require transfer to a LTACH.  
 
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 the enrollee was admitted with acute on chronic hypercapnic and hypoxic respiratory 
failure secondary to multifocal pneumonia and superior vena cava syndrome.  
 The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services and these 
have not been denied. The medical record does not indicate that the enrollee requires services not currently 
receiving but that would be available at the LTACH facility. The elements of coverage rules are not satisfied. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided on August 27, 2023. 
 
You asked the Plan to pay for the inpatient stay. The Plan denied your request. The Plan says that there was no 
documentation of fast heartbeat or low blood pressure, swelling of both kidneys, or severe vomiting or pain that 
could not be controlled during the observation period. The Plan also says this admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 stay. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found there was reasonable expectation you would be admitted for two midnights. You not only had 
hydroneprhosis related to a kidney stone, but you also had an inguinal hernia that had signs of possible 
incarceration. Our reviewer found that you required bowel rest and hydration. Our physician reviewer also 
found that there were clear indications for a two-midnight admission. 
 
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 inpatient stay have been met. Therefore, we decided that the Plan has to pay 
for the inpatient stay provided on August 27, 2023.  
 
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 an additional unit of procedure code 88305 rendered on April 
6, 2023.  
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 this service is a duplicate. 
 
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 88305 is Level IV - Surgical pathology, gross and 
microscopic examination." 
 
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 two units are not justified. The 
cases have the same accession number. Only one unit should have been billed. 
 
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 an additional unit of procedure code 88305 rendered on April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Mis reader. 
 
You asked the Plan to pre-approve the Dexcom G7 Mis reader. You say that the medical records provided 
support the need for the requested Dexcom G7. The Plan denied your request. The Plan says Medicare 
guidance says a CGM is covered under Medicare only if an enrollee with diabetes is on insulin or has 
documentation of very low blood sugars that has occurred several times.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7 Mis reader. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or 
has problematic hypoglycemia as defined by Medicare. The elements of the coverage criteria are not satisfied.  
 
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 Dexcom G7 Mis reader. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 Mis reader.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99233) 
provided on March 1, 2023. 
 
You asked the Plan to pay for the subsequent hospital inpatient or observation care. The Plan denied your 
request. The Plan says the billed services were 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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
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 subsequent hospital inpatient or observation care. Our 
reviewer found the documentation does not support this level of billing, neither by complexity of medical 
decision making or time spent. 
 
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 subsequent hospital inpatient or observation care have not been met. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital inpatient or observation 
care (99233) provided on March 1, 2023.