Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 4, 2022 
to November 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that it is 
anticipated that upon careful review of the medical record the original determination will be overturned. The 
Plan denied your request. The Plan says the review did not find sufficient documentation to clinically validate 
the diagnosis code for Acute and chronic respiratory failure with hypoxia (J96.21). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.21, defined as Acute 
and chronic respiratory failure with hypoxia. 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 hospital services at the DRG originally billed. Our reviewer says that the submitted DRG is not 
supported. Our physician reviewer found the patient was admitted to the hospital with multiple traumas and 
was treated with oxygen via nasal cannula during the hospital stay. They did not require high flow oxygen, vent 
support, or bilevel positive airway pressure (BiPAP) and did not exhibit persistent respiratory distress to meet 
the criteria for acute respiratory failure. Our reviewer found that therefore, the secondary diagnosis code, 
J96.21 Acute and chronic respiratory failure with hypoxia, is not sufficiently supported in the documentation 
for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from November 4, 2022 to November 7, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99203-25 billed on date of service May 19, 2023. 
 
You asked the Plan to pay for 99203-25. You say that the 99203-25 should be paid as billed because it 
represents a significant, separately identifiable evaluation and management service from that which is included 
in payment for the minor procedure performed on the same date. The Plan denied your request. The Plan says 
payment for 99203-25 is denied because it is included in the payment for the minor procedure performed on the 
same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say in general, evaluation and 
management services on the same date of service as a minor surgical procedure are included in the payment for 
the procedure. A significant and separately identifiable evaluation and management service unrelated to the 
decision to perform the minor surgical procedure is separately reportable with modifier -25. 
 
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 99203-25. Our reviewer says that 99203-25 does not 
represent a significant, separately identifiable evaluation and management service above and beyond that 
associated with the minor procedure coded as 20610 performed on the same date by the same provider. Our 
reviewer found the medical record does not support that while performing the evaluation and management 
services, a significant separately identifiable service was performed. The enrollee presented to the office for 
knee pain and an injection was performed for the knee pain. No other problems were documented. 
 
We looked at this coder's review, the file, and Medicare rules. We confirmed that 20610 is a minor procedure 
with a global period of 000 days. This procedure was performed on the same date of service by the same 
provider as 99203-25. Although modifier -25 was appended in this case, records do not support that 99203-25 
was a significant and separately identifiable evaluation and management service. Based on this information, we 
decided that Medicare rules for coverage of 99203-25 has not been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services described by code 99203-25 billed on date of 
service May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you are trying to control your pre-diabetes. The Plan 
denied your request. The Plan says the medical criteria for a CGM has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81226, 81240, 81241, and 
81328. We decided that the Plan does not have to pay for the services described by procedure code(s) 81225, 
81227, 81231, 81232, 81306, and 81335.  
 
You asked the Plan to pay for procedure codes 81226, 81240, 81241, 81328, 81225, 81227, 81231, 81232, 
81306, and 81335 provided on May 8, 2023. You say that you would like the Plan to reconsider their denial of 
payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81226, 81240, 81241, 
and 81328.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81226, 81240, 81241, and 
81328.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81225, 81227, 81231, 81232, 81306, and 81335. 
 
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 services described 
by procedure code(s) 81225, 81227, 81231, 81232, 81306, and 81335 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 81225, 81227, 
81231, 81232, 81306, and 81335. 
 
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: 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 the enrollee has a history of iron deficiency. The 
Plan denied your request. The Plan says that the step therapy requirements have not been met.  
 
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 that the enrollee has not tried and failed the 
Plan's required drugs ferrous sulfate, ferrous gluconate, or ferrous fumarate. Also, there is no indication that the 
Plan's required drugs would likely be less effective 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; complex (77525). 
 
You asked the Plan to pre-approve proton treatment therapy. You say that you are requesting reconsideration 
and have submitted medical records for review. The Plan denied your request. The Plan says a review of the 
current medical literature does not consider this service to be standard medical treatment for the enrollee's 
condition. 
 
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 proton treatment therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is being offered palliative radiotherapy and because of prior palliative 
radiotherapy (3 Gray (Gy) x 10) in the same site, proton therapy was recommended. In general, proton therapy 
is not needed for palliation, though could be considered in situations in which conventional radiotherapy or an 
intensity modulated radiation therapy (IMRT) would be unsafe. For this case, there is no evidence or plausible 
reason why IMRT/volumetric modulated arc therapy (VMAT) plan would be unacceptable for this enrollee 
with a poor prognosis. There is no specific justification for proton therapy in the enrollee with no specifics on 
the treatment plan or target volume. The decision is therefore unfavorable for lack of demonstration of need. 
Routine use of proton therapy for palliation, even in the setting of prior radiation, is not standard of care with 
justifying the need with a dosimetric rationale. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton treatment delivery; complex (77525).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2023, to 
March 27, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.23, described as acute 
on chronic systolic (congestive) heart failure. 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 hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee was hospitalized with severe aortic stenosis 
(AS). This is a chronic and progressive condition, which for this enrollee had finally reached the point where 
intervention was indicated. The enrollees symptoms appear to be entirely attributable to her AS. There is no 
evidence that the enrollee had acute heart failure. As such, the billing of I50.23 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 15, 2023, to March 27, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee needs a CGM. The Plan denied your 
request. The Plan says the enrollee does not meet the medical criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor 
(CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for batteries for hearing devices provided on June 21, 
2023. 
 
You asked the Plan to reimburse for batteries for hearing devices. You say that this is part of the cost of hearing 
aids and should be covered in  your claim. The Plan denied your request. The Plan says this is not a covered 
expense. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only. Batteries for hearing devices are excluded from this benefit. 
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
batteries for hearing devices provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Image Guided Radiation Therapy (IGRT) (77387). 
 
You asked the Plan to pre-approve IGRT. You say that the requested therapy is medically necessary. The Plan 
denied your request. The Plan says that there is no evidence submitted that an optimized 3D conformal plan 
fails to meet tolerances of nearby organs at risk. 
 
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 IGRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT utilizes imaging technology to modify treatment delivery to account for changes in the 
position of the intended target. IGRT is indicated for use in enrollees whose tumors are located near or within 
critical structures and/or in tissue with inherent setup variation but does not specify when it is necessary. The 
main rationale offered for IGRT in this case is that they use a commercial system that relies on superficial 
guidance. While the use of IGRT is perhaps debatable and not strongly supported by National Comprehensive 
Cancer Network (NCCN) guidelines, its potential to reduce heart and lung exposures by improving set-up 
accuracy is plausible and arguably it would be within accepted standards of care particularly with enrollees 
with high body mass index (BMI). The decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have been met. Therefore, we decided that the Plan has to pre-approve 
Image Guided Radiation Therapy (IGRT) (77387).  
 
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 molecular diagnostic testing provided on November 8, 2022. 
 
You asked the Plan to pay for molecular diagnostic tests. You say that documentation supports this testing and 
billing. The Plan denied your request. The Plan says this testing should have been billed with a single 
procedural code. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic testing should be billed 
with 1 unit of service of a single appropriate procedure code.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of molecular diagnostic tests have not been met. 
Therefore, we decided that the Plan does not have to pay for molecular diagnostic testing provided on 
November 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan with CT scan.  
 
You asked the Plan to pre-approve a PET scan with CT scan. The Plan denied your request. The Plan says a 
PET scan with CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan with CT scan. Our reviewer 
says that a PET scan with CT scan is not medically necessary. Our physician reviewer found that you have a 
history of mantle cell lymphoma, and you cannot tolerate oral contrast and your renal function is too high for 
intravenous line (IV) contrast. Also, you have enlarged abdominal lymph nodes that are being monitored since 
2021. Also, the lymph nodes have increased and decreased in size since that time and on a CT without IV 
contract on June 5, 2023, the nodes were noted to have decreased. Additionally, a PET scan is not indicated for 
the surveillance of mantle cell lymphoma, chronic lymphocytic leukemia, or enlarged lymph nodes even if no 
IV or positive oral contrast could be used. Therefore, the service is not reasonable or 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 PET scan with CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PET scan with CT scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6752), and an additional intraoral image 
(D0230) provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like you were given false information. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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 one retainer crown was approved and paid on February 21, 2023. Therefore, we decided that the Plan does not have to pay for a retainer crown (D6752), and an additional intraoral image (D0230) provided on 
February 21, 2023.