Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit 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 
an office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on February 23, 2023, to June 27, 
2023. 
 
You asked the Plan to pay for office visits. You say that you have been with this plan for many years. They 
should be able to cover this for you. 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 office visits provided on 
February 23, 2023, to June 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services described by code 01938 performed on date of 
service May 19, 2023. 
 
You asked the Plan to pay for 01938. You say that 01938 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says that 01938 is denied because it was billed without 
the required -QS modifier. 
 
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 rules also say that when procedure code 01938 is used and MAC has been provided, the -QS 
modifier must be used. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the case file does not contain a claim image or copy of the claim 
submitted by the provider to the Plan. Without this information, we are unable to confirm whether a modifier 
was appended to code 01938, and if so, which one. Also of note, the LCA cited by the Plan indicates that the -
QS modifier must be appended when code 01938 is used, and MAC is provided. In this case, records contain 
evidence that MAC was not provided. Therefore, we decided that the Plan has to pay for the anesthesia services 
described by code 01938 performed on date of service May 19, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for Truxima to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit for Truxima 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 
an office visit for Truxima to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Rexulti. 
 
You asked the Plan to pre-approve the medication. You say that Rexulti is medically necessary for the 
enrollee's treatment. 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 the use of Rexulti.  
 
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 lab services (81240, 81241, 81328) provided on May 26, 
2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
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. 
 
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 lab services. Our reviewer says that the use of codes 
82140, 81241, and 81328, is not supported by the records provided. Our reviewer found that the procedure 
report documents "Buccal swab". The billed procedures are performed with whole blood. In this case, the billed 
services 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 the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (81240, 81241, 81328) provided on May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Level IV - surgical pathology, gross and microscopic 
examination (88305) and decalcification procedure (list separately in addition to code for surgical pathology 
examination) (88311) provided July 27, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the remittance provides no explanation as to 
why this claim has not been paid. Please review and provide additional information. The Plan denied your 
request. The Plan says the claim/service lacks information or has submission/billing errors. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88305 is Level IV - surgical pathology, gross and microscopic examination and 88311 is decalcification procedure (list separately in addition to code for surgical 
pathology examination). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory service. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found 88305 is not supported. The 
documentation does not contain a description of a microscopic examination of the specimen. 88311 is also not 
supported. The documentation states that de-calcification was performed, but does not specify where, who, or 
when it was performed. It cannot be verified that this was part of the pathology service provided.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Level IV - surgical pathology, gross and microscopic examination (88305) and 
decalcification procedure (list separately in addition to code for surgical pathology examination) (88311) 
provided July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dayspring Active Compression System and leg 
garment (K1024 and K1033). 
 
You asked the Plan to pre-approve the Dayspring Active Compression System and leg garment. You say that 
the items are medically necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 the Dayspring Active Compression 
System and leg garment. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is insufficient evidence in the medical literature 
to support that the requested Dayspring device is as effective as a pneumatic sequential compression device. 
 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 Dayspring Active Compression System and leg garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Dayspring Active Compression System 
and leg garment (K1024 and K1033).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on July 12, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM), 
supplies and accessories provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 14, 2023, billed with 
procedure code 00840. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim has not been billed with the required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when anesthesia codes are used and MAC has 
been provided, the QS modifier must be used. 
 
We looked at the file and Medicare rules. The claim has not been reported with the required QS modifier. 
Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on July 14, 2023, billed with procedure code 00840.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft. 
 
You asked the Plan to pre-approve bone graft. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
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 bone graft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that allograft is experimental when used as bone graft. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone graft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve bone graft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stretta procedure.  
 
You asked the Plan to pre-approve the Stretta procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the Stretta procedure is non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Stretta procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Stretta procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve implantation of a Barostim Neo system. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 implantation of a Barostim Neo system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a 
result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a Barostim Neo system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a Barostim Neo system (0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly AM skin substitute. 
 
You asked the Plan to pre-approve PuraPly AM skin substitute. You say that you would benefit from skin 
substitute to promote faster wound closure and get out of pain. The Plan denied your request. The Plan says 
PuraPly AM skin substitute is 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 pre-approve PuraPly AM skin substitute. Our 
reviewer says that the requested PuraPly AM skin substitute is not considered medically reasonable and 
necessary. Our physician reviewer found that based on the medical records provided there is inadequate 
support for the use of the PuraPly AM skin substitute for your wound. The provided medical records, review of 
the manufacturer's documentation and review of the current peer-reviewed medical literature do not document that use of the PuraPly AM skin substitute has been shown in placebo-controlled studies in a CMS-approved 
journal to result in sustained long term health benefits in the Medicare population with non-healing 
arterial/venous ulcers.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly AM skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve PuraPly AM skin substitute.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided April 3, 
2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says provider billed CPT 99285 and the claims were downcoded to CPT code 99284. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 service. Our reviewer found the history was minimal and 
there was essentially no physical exam. The enrollee presented for headache but resolved by the time the 
enrollee arrived. There was no evidence of life or limb threatening condition. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit (99285) provided April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation. 
 
You asked the Plan to pre-approve intraosseous basivertebral nerve ablation. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is 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 pre-approve intraosseous basivertebral nerve 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no magnetic resonance imaging showing only 
modic changes without facet degenerative joint disease or stenosis. The cause of pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intraosseous basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be improving on current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. The patient does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as it would 
not be clinically advantageous. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-adjunctive, non-implanted continuous glucose monitor 
on October 2, 2023. 
 
You asked the Plan to pay for a non-adjunctive, non-implanted continuous glucose monitor. You say that you 
would like to request reconsideration for payment. The Plan denied your request. The Plan says the proof of 
delivery submitted is invalid because it was not signed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery submitted is invalid because it was 
not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a non-adjunctive, non-implanted 
continuous glucose monitor on October 2, 2023.