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

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99236) 
rendered on July 3, 2022. 
 
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 the denied code remains 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 99236 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) requiring admission are of high severity. Typically, 55 
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 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 enrollee was treated in the 
hospital and placed under observation care for lightheadedness following a margarita drink at a restaurant. The 
enrollee was discharged the same day. The documentation supported an appropriate history and examination. 
However, the documentation from this date did not support medical decision making of high complexity as the 
enrollee was stable and did not require invasive or complex treatment.  
 
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 evaluation and management services (procedure code 99236) rendered on July 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 0037U for May 22, 
2023. 
 
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 payment is included in payment to the SNF. 
 
The Plan must follow Medicare rules. The rules say that laboratory tests performed for the skilled nursing 
facility (SNF)'s Medicare inpatients covered under Part A are included in the prospective payment system 
(PPS) SNF payment. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered to a SNF 
inpatient. Payment for these services is included in the PPS SNF payment. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with code 0037U for May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22612). 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the requested service is a necessity 
for your care. The Plan denied your request. The Plan says the requested service 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 a Minuteman procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Minuteman device is experimental. More research is needed to demonstrate its safety 
and efficacy. 
 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 Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the diagnosis code at 
issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code D63.8. This code 
is not an appropriate primary diagnosis as the code definition includes in diseases classified elsewhere, which 
means it is a manifestation code. Based on this information, we decided that Medicare rules for payment of this 
claim have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on 
March 21, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a magnetic resonance imaging (MRI) of the lower spine received on 
December 22, 2022. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says that there was no prior authorization requested for the MRI. 
 
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. The Plans denial reason is invalid. Therefore, we decided that the Plan has to 
pay for a magnetic resonance imaging (MRI) of the lower spine received on December 22, 2022.  
 
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 procedure code 86320 provided on March 30, 2023. 
 
You asked the Plan to pay for procedure code 86320. 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 providers must report services correctly. The 
rules say that the TC and 26 modifiers should not be used with codes with a PC/TC indicator of 9, as the 
concept of a professional and technical component does not apply to these codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 86320 have not been met. Specifically, code 86320 has a PC/TC indicator of 9 
but was billed with modifier 26. It is not appropriate to use modifier 26 with code 86320. Therefore, we 
decided that the Plan does not have to pay for procedure code 86320 provided on March 30, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees current level of functioning as of October 23, 2023, is contact guard assist for ambulation 
of 60ft with front wheel walker and contact guard assist for sit to stand transfer. Although the member has had 
a decline in level of function, their skilled therapy needs could be met in a lower level of care. While the 
member has multiple medical issues, these issues are stable and do not complicate care in the current setting. 
The enrollee does require physical and occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a Membrane graft/wrap. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no evidence of infection noted. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a chronic non-healing posterior right thigh venous ulceration. A review of 
the current peer-reviewed literature documents that the use of skin substitutes has been shown in controlled 
studies to improve healing of chronic wounds including chronic venous ulcers and pressure-related injuries; the 
type of skin substitute requested in this case has been used for managing burn wounds, diabetic foot ulcers, 
venous leg ulcers, pressure ulcers, surgical wounds, and traumatic wounds. The cited review from Up to Date 
does not place a time limit on the use of skin substitutes. This request is needed to avoid an extensive surgical 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve a Membrane graft/wrap.  
 
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 oxygen equipment provided on March 6, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that Medicare coverage is not diagnosis-driven 
and the enrollee qualifies for oxygen equipment. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J96.11 has an Excludes1 note in relation to R06.3. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for 
oxygen equipment provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798 and 87801) provided on June 15, 
2023. 
 
You asked the Plan to pay for procedure codes 87798 and 87801. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87798 and 87801 are not supported in the medical record. Specifically, a panel was 
performed and there is a more appropriate singular code for the services. 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 the panel testing (87798 and 87801) provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over the bed table (E0274) and non-sterile gloves 
(A4927). 
 
You asked the Plan to pre-approve the over the bed table and non-sterile gloves. You say that you had 
purchased a table it is worn out and wobbly and the enrollee needs a new one. The medical gloves are 
necessary and required for proper care. The Plan denied your request. The Plan says Medicare does not cover 
over the bed table or non-sterile gloves. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the over the bed table (E0274) and non-sterile gloves 
(A4927).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation (64624, J1100). 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 genicular nerve ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve ablation is experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation (64624, J1100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair repairs (E2370, K0108, K0739). 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the enrollee is a quadriplegic and needs 
wheelchair repairs. The Plan denied your request. The Plan says the enrollee resides in a long-term care facility 
and Medicare does not cover wheelchair repairs when a member resides in a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair repairs are being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve the power wheelchair repairs (E2370, K0108, K0739).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 1, 2023, to April 
6, 2023. 
 You asked the Plan to pay for the home health services. You say that other claims for this patient have been 
paid. The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from April 1, 2023, 
to April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable queen size bed. 
 
You asked the Plan to pre-approve the adjustable queen size bed. You say that this bed is medically necessary. 
The Plan denied your request. The Plan says the requested bed is not a hospital bed, and is not primarily a 
medical item. It is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an adjustable queen size bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis reader. 
 
You asked the Plan to pre-approve the Dexcom G6 Mis reader. You say that the CGM is medically necessary 
for testing blood sugars daily to maintain control and prevent complications. The Plan denied your request. The 
Plan says the enrollee is not on insulin and does not have documentation of problematic hypoglycemia. 
 
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 G6 Mis reader. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found coverage criteria for 
CGM include insulin use or low blood glucose sugar. The enrollee is not on insulin and is not having low blood 
glucose sugar. Although Ozempic is being added, the enrollee is not on medications that cause low blood 
glucose sugar. Coverage criteria for CGM are not met. 
 
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 G6 Mis reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 Mis reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance for treatment of sleep apnea (E0486). 
 
You asked the Plan to pre-approve an oral appliance. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve an oral appliance for treatment of sleep apnea (E0486).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Infed or Venofer is required before alternatives can be considered. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs or any reason they are unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.