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

 
We decided that the Plan does not have to pay for wound care supplies provided on June 20, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. 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 wound care supplies 
provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 10, 
2023. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. 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 procedure code 
99100 billed for date of service May 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22899 provided on July 3, 2023. 
 
You asked the Plan to pay for procedure code 22899. You say that the medical records support two units of 
procedure code 22899. The Plan denied your request. The Plan says two units of procedure code 22899 were 
billed, and the medical records only support one unit of procedure code 22899. 
 
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 22899 is Unlisted procedure, spine. 
 
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 22899. Our reviewer says that two units of 
procedure code 22899 were billed, and the medical records only support one unit of procedure code 22899. Our 
reviewer found the medical record includes the operative report for the procedures performed on the spinal 
column, however an unlisted procedure was not included in the 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 22899 have not been met. Therefore, we decided that the Plan 
does not have to pay for the second unit of procedure code 22899 provided on July 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan 
denied your request. The Plan says the enrollee will not be able to participate or fully benefit from IRF 
services.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing can detect minimum residual disease. 
The Plan denied your request. The Plan says an appropriate code was not billed. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
The file shows that a Guardant Reveal test was provided. We looked at the file and Medicare rules. The claim 
does show that a unique identifier was billed. However, the test was reviewed and did not meet Medicare 
reasonable and necessary requirements. 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 lab testing billed for date of 
service September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 18, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim needs to first be submitted to the enrollee's 
primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer and contacted you multiple times (on October 12, 2023, and October 18, 2023) to bill the 
primary insurer.. As the secondary insurer, the Plan cannot be held responsible for the medical services until 
the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have 
to pay for medical services provided on April 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. You asked the Plan to pre-approve the 
medication. You say that the enrollee has failed medical treatments and dietary modifications. 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 pre-approve Xifaxan.  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81249, 81306, 81328, 81335, 81350, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 2, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81249, 81306, 81328, 
81335, 81350, and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that all of this dental work was medically necessary. 
The Plan denied your request. The Plan says your annual dental allowance amount has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit $1,000 annual dental allowance amount was exhausted on date of service July 19, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220) provided on July 19, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair and accessories (E0955, E1002, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2603, K0040, K0856). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 3 power wheelchair and 
accessories. Our reviewer says that the services are medically necessary. Our physician reviewer found the 
enrollee is non-ambulatory and cannot use a cane or walker for mobility. The enrollee requires a power 
wheelchair for mobility and accomplishing their daily activities. The enrollee requires a group 3 power 
wheelchair with power tilt given that there is a history of a sacral pressure wound and the enrollee is unable to 
independently perform pressure relief. The enrollee also requires a power seat elevator to provide increased 
independence with transfers and power articulating foot platform for positioning of the lower extremities and 
lower extremity edema. Therefore, the group 3 power wheelchair with power tilt, power lift and power 
articulating foot platform are 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 a group 3 power wheelchair and accessories have been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair and accessories (E0955, E1002, E1012, 
E1028, E2300, E2311, E2313, E2361, E2377, E2603, K0040, K0856).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76000-26-XU, 20930 and 20936 billed for 
date of service June 29, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes are 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 find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 20930 and 20936 are not separately payable. 
 
We find that code 76000 is a column II code to column I code 22612. Code 76000 was billed with an XU 
modifier. The records do not show that code 76000 was an unusual non-overlapping service. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 76000-26-XU, 20930 and 20936 billed for 
date of service June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99497 and G0317 for date of service April 28, 2023. 
 
You asked the Plan to pay for codes 99497 and G0317. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
The CPT Code Manual definition of code G0317 is prolonged nursing facility evaluation and management 
service(s) beyond the total time for the primary service (when the primary service has been selected using time 
on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare 
professional, with or without direct patient contact (list separately in addition to cpt codes 99306, 99310 for 
nursing facility evaluation and management services). (do not report g0317 on the same date of service as other 
prolonged services for evaluation and management 99358, 99359, 99418). (do not report g0317 for any time 
unit less than 15 minutes). 
 
We find that CPT codes 99497 and G0317 are not supported in the medical record. Specifically, the submitted 
medical records do not include the documentation of a discussion between the provider and the patient, along 
with family member, or surrogate, regarding eventual end-of-life decisions and preferences; therefore, code 
99497 is not supported. 
 
The submitted medical records do not support that prolonged nursing facility evaluation and management 
service(s) beyond the total time for the primary service was performed; therefore, code G0317 is not supported. 
In addition, this code is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on this information, we decided that Medicare rules for coverage of codes 99497 and G0317 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 99497 and G0317 for date of 
service April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-evaluation (D0170), the bone replacement graft 
(D4263, D4264, and D7953), the biologic materials (D4265), the unspecified periodontal procedure (D4999), 
the anesthesia (D9239), and an office visit (D9430) provided on January 24, 2023, January 31, 2023, February 
7, 2023, March 15, 2023, July 11, 2023, and August 17, 2023. You asked the Plan to pay for the dental services. You say that you want the dental codes to be improved so 
they can be covered. The Plan denied your request. The Plan says the denial of authorization for these services 
is correct, because the re-evaluation, the bone replacement graft, the biologic materials, the unspecified 
periodontal procedure, the anesthesia, and an office visit are not covered by the Plan. 
 
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 the re-
evaluation (D0170), the bone replacement graft (D4263, D4264, and D7953), the biologic materials (D4265), 
the unspecified periodontal procedure (D4999), the anesthesia (D9239), and an office visit (D9430) provided 
on January 24, 2023, January 31, 2023, February 7, 2023, March 15, 2023, July 11, 2023, and August 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 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 prochlorperazine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for four skin debridement procedures (11042 
x4) provided from July 20, 2023, to August 10, 2023. 
 
You asked the Plan to waive the copayments for skin debridement procedures. You say that you were never 
told about the $225 copay. You also say this was not done in an outpatient setting, and if you would have 
known the price, you would not have had the procedure done multiple times. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copay per visit, per provider, per day for surgery performed in an outpatient hospital setting under the 
outpatient hospital services benefit category  
You have been asked to pay a $225 copay per visit for the skin debridement procedures. This service falls 
within the outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
four skin debridement procedures (11042 x4) provided from July 20, 2023, to August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccination administered on June 13, 2023. 
 
You asked the Plan to pay for the shingles vaccination. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that their original decision to deny payment was correct. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccination. Therefore, we decided that the Plan does not have to pay for the shingles vaccination administered 
on June 13, 2023.  
 
  Benefits for the shingles vaccination 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just had back surgery and are needing rehab to 
regain maximum level of function. You say that you also had double knee surgery and need this therapy. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.