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

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for these services 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 14 units of procedure code 88341 rendered on February 20, 
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 that while the documentation does support that excess units were provided, they have not given 
any specific rationale as required by the policy as to why additional units needed to be performed. 
 
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 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 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 supports that 
the additional units were rendered in this case, but there is no clear documentation as to why these additional 
units were necessary. 
 
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 14 units of procedure code 88341 rendered on February 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography cerebral perfusion analysis (CTP) 
rendered on March 22, 2023. 
 You asked the Plan to pay for the services. You say that you have submitted supporting documentation for 
reconsideration of the denied code. The Plan denied your request. The Plan says this was not medically 
necessary. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record provided is insufficient to determine whether the time elements of the rule are 
satisfied. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for computed tomography cerebral perfusion analysis (CTP) rendered on March 22, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37253 rendered on January 16, 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 Current Procedural Terminology (CPT) code 37253 (1 unit) 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 37253 is "Intravascular ultrasound (IVUS) (noncoronary 
vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)." 
 
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 coverage of the code in question. IVUS of the aorta was performed, billed, and covered.  There is no 
evidence that additional vessels underwent IVUS. The documentation of IVUS findings was very limited and 
without detail.  The documentation does not justify coding or billing of IVUS of additional vessels. 
 
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 37253 rendered on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flu vaccination to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a flu vaccination to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a flu vaccination to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on March 15, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  non-contact fluorescence imaging device provided on April 
25, 2023. 
 
You asked the Plan to pay for  non-contact fluorescence imaging device. You say that you are requesting 
reconsideration of the denied claim for medical necessity. The Plan denied your request. The Plan says this 
service does not meet this requirement of the enrollee's health Plan.  
 
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 pay for non-contact fluorescence imaging device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the clinical value and effectiveness of MolecuLight in the setting of 
fluorescence imaging of wounds with a handheld device has not been demonstrated. The review has determined that the items/services at issue in this case are not medically reasonable or 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 non-contact fluorescence imaging device have not been met. Therefore, we 
decided that the Plan does not have to pay for  non-contact fluorescence imaging device provided on April 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 30, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration asking for the 
documents to be reviewed. 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 an office visit provided 
on April 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 04, 
2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you feel that you should not be 
responsible for the copayment. 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 $200 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $200 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 copayment for outpatient surgery provided on 
May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each wound debridement provided on April 
13, 2023, to June 22, 2023. 
 
You asked the Plan to waive the copayment for each wound debridement. You say that you want to appeal the 
amount being charged. 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 $200 
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $200 copayment for each wound debridement. This item/service falls within the outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers 
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. The 
total you owe is $2,200 ($200 copayment x 11 visits = $2,200). Therefore, we decided that the Plan does not 
have to waive the copayment for each wound debridement provided on April 13, 2023, to June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74230, 72040, 70100, 70310, and 74240 
provided on March 22, 2023. 
 You asked the Plan to pay for procedure codes 74230, 72040, 70100, 70310, and 74240. 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. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. Medicare rules also say that the technical component of a 
portable x-ray service during the course of a Medicare-covered stay in a skilled nursing facility (SNF), 
representing the procedure itself, including any associated transportation and setup costs, would be subject to 
consolidated billing (the SNF bundling requirement for services furnished to the SNFs Part A residents), and 
must be included on the SNFs Part A bill for the residents covered stay rather than being billed separately 
under Part B. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the billed services (74230, 72040, 70100, 70310, and 74240) have not been met. The 
documentation supports that the enrollee was at a skilled nursing facility setting on the date of service. As such, 
the use of the office POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for 
procedure codes 74230, 72040, 70100, 70310, and 74240 provided on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 09, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
December 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visit in a facility provided on May 19, 2023. 
 
You asked the Plan to pay for a visit in a facility. You say that you have submitted supporting documents for 
medical necessity, please reconsider. 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 a visit in a facility 
provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on March 30, 2023. 
 
You asked the Plan to pay for procedure code 99222. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines.   
We looked at the file and Medicare rules. In this case, coding guidelines state that codes from category Z01 
should only be used as principal or first-listed codes. Z01.89 is incorrectly billed in this case. Therefore, we 
decided that the Plan does not have to pay for procedure code 99222 provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 10, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says new documents were submitted for this appeal and consist of encounter 
notes and treatment notes for various dates other than the billed date of service. Duplicates of records 
previously reviewed were also submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physical therapy have been met.  
Therefore, we decided that the Plan does not have to pay for physical therapy provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit, and the comprehensive 
hearing test provided by an in-network provider on May 1, 2023. 
 
You asked the Plan to waive the copayment for the office visit, and the hearing test. You say that you do not 
agree with the cost sharing. 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 $35 
copayment for each in-network Medicare-covered hearing exam, and a $35 copayment for each in-network 
Medicare-covered specialist office or telehealth visit. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a $35 copayment for the hearing test. This item/service falls within the hearing 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 copayment for the office visit, and the comprehensive hearing test provided 
by an in-network provider on May 1, 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 have no way of checking your sugar levels. The 
Plan denied your request. The Plan says the medical criteria for a CGM have 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 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 continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone tablets. 
 
You asked the Plan to pre-approve the medication. You say that this drug is medically necessary. 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. The records do not show that the drug is being used as a full replacement for intravenous anti-
emetic drugs. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone tablets.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 26, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. 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 home visit provided 
on April 26, 2023.