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 on August 19, 2022, to 
August 25, 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 the 
claim was 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 principal diagnosis code A41.59, described as Other 
Gram-negative sepsis. 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 the enrollee was hospitalized with a non-healing toe infection, for which an 
amputation was performed. Initial blood cultures were positive (i.e., bacteremia). Intravenous antibiotics were 
provided. No signs of hypotension, hypoperfusion, or organ failure are noted (i.e., sepsis).  
 
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 August 19, 2022, to August 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service October 12, 
2022. You asked the Plan to pay for procedure code 11721. You say that medically necessary services were provided 
in good faith. The Plan denied your request. The Plan says payment for code 11721 is bundled into payment for 
code 11055. 
 
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, we have confirmed that code 11721 is a column II code to column I code 11055. Code 11721 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 11721 
billed for date of service October 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve albuterol. 
 
You asked the Plan to pre-approve albuterol. You say that the enrollee has tried levalbuterol and it makes them 
feel miserable and is not helping them with their symptoms. You say that the enrollee wants their albuterol 
back. The Plan denied your request. The Plan says self-administered drugs do not fall under Medicare Part B 
coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve albuterol.  
 
Benefits for albuterol 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the treatment. 
The Plan denied your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. The code is used to identify 
drug Bupivacaine, a local anesthetic, which is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code J3490 billed for date of service December 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computerized corneal topography and scanning 
computerized ophthalmic diagnostic imaging. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirement is a diagnosis of irregular astigmatism. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
testing was performed in anticipation for cataract surgery, however there is no diagnosis of irregular 
astigmatism. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computerized corneal topography and scanning computerized ophthalmic diagnostic imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service October 4, 
2022. You asked the Plan to pay for procedure code 93010. The Plan denied your request. The Plan says payment for 
code 93010 is bundled into payment for code 93294. 
 
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, we have confirmed that code 93010 is a column II code to column I code 93294. CPT code 93010 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
93010 billed for date of service October 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 5, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the discharge from the hospital should be 
covered by this plan. The Plan denied your request. The Plan says this claim does not meet the requirements for 
non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance transport was not medically necessary. Our physician reviewer found the transportation via 
ambulance from the hospital to the enrollee's residence upon discharge was not medically necessary. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport.  Oxygen is routinely used/administered by laypersons via portable oxygen 
tank/concentrator. Transportation could have been provided by other means (stretcher van, wheelchair van, 
private car, taxi) without endangering the enrollee's condition.  
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and eyeglasses provided on November 7, 2022.  
You asked the Plan to pay for the exam and eyewear. You say that you were told that as long as you got the 
eyewear within 3 months of the new year, it would be covered. The Plan denied your request. The Plan says 
review of call logs do not show that you were told that the eyewear would be covered within three months of 
the new year. This benefit can only be used once per year and was used in March 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per calendar year.  
 
We looked at the file and the Plan's rules. You received an eye exam and eyeglasses in March 2022. This 
benefit was exhausted for 2022 at that time. Based on this information, we decided that the Plan's rules for 
coverage of the exam and eyewear have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye exam and eyeglasses provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99204) rendered on July 12, 
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 Current Procedural Terminology (CPT) code 99204 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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 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 stable, and the 
records did not sufficiently support medical decision-making of a moderate level. Also, the documentation did 
not include time stamps or duration of services rendered on that date to support the required 45-59 minutes for 
this code.  
 
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 an office visit (procedure code 99204) rendered on July 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 8, 2022, billed with 
procedure codes 31636, 31625, and 31645. 
 You asked the Plan to pay for the medical services. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) codes 31636, 31625, and 31645 
remain unsupported. 
 
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, we have confirmed that code 31630 is a column II code to column I code 31636; however, 31630 
was billed with a modifier.  
 
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 medical services. Our reviewer says that the 
documentation does not support procedure codes 31636, 31625, and 31645. Our reviewer found that the 
medical record has insufficient documentation to confirm the procedures have been performed, or if they are 
inclusive to another service provided. In this case, a procedure report is not included in the medical record and 
therefore cannot be verified.  The documentation states status post bronchoscopy. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on August 8, 2022, billed with procedure codes 31636, 
31625, and 31645.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gamma knife radiosurgery treatment to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON gamma knife radiosurgery treatment. You say that the enrollee 
still wants the requested treatment done at the OON facility to avoid further symptoms if the brain tumor 
continues to grow. The Plan denied your request. The Plan says there are network providers who are able to 
supply the treatment requested. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve gamma knife radiosurgery treatment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide In-Vitro strips (A4253). 
 
You asked the Plan to pre-approve Accu-Chek strips. You say that you have diabetes, and you are already 
using the requested product. The Plan denied your request. The Plan says only the preferred brand products 
listed in the EOC are covered. 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Accu-Chek strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Guide In-
Vitro strips (A4253).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on October 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgery 
services are not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 63650. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgery 
services provided on October 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Panzyga (J1599). 
 
You asked the Plan to pre-approve Panzyga. You say that the requested drug is medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says the documentation does not indicate you are 
intolerant of azathioprine. The Plan also says this medication is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that intravenous immune globulin (IVIG) is indicated for 
treatment of myasthenia gravis (MG) in patients who have profound, rapidly progressive and/or potentially life-
threatening muscular weakness and are refractory to, or intolerant of cholinesterase inhibitors, corticosteroids 
and azathioprine. 
 
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 Panzyga. Our reviewer says that the 
requested drug, Panzyga, is not medically necessary. Our physician reviewer found the provided records do not 
document the enrollee has profound, rapidly progressive, or potentially life-threatening disease or that she has 
intolerance to azathioprine. The medical records provided do not indicate that the Panzyga at issue in this case 
meets all Medicare criteria for medically reasonable and necessary and safe and effective 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 Panzyga have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Panzyga (J1599).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a negative pressure wound therapy (NPWT) pump.  
You asked the Plan to pre-approve NPWT pump. You say that you do not, nor have to ever had an 
enterocutaneous or colocutaneous fistula. The Plan denied your request. The Plan says that the records show a 
wound vac over an openly draining enterocutaneous fistula. 
 
The Plan follows Medicare rules. Medicare rules state that NPWT pumps may be covered if certain criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve NPWT pump. Our reviewer says that 
you meet criteria for the requested NPWT pump. Our physician reviewer found you have a medical history of a 
colovesical fistula and underwent colostomy reversal and creation of an omental flap on February 1, 2023. You 
had a midline wound due to the infected nature of your condition and required a wound vac for healing. The 
documentation indicated that your wound vac was placed for a contaminated wound and not for a fistula. You 
were noted to have a history of colovaginal fistula, but this was not the reason for the placement of the wound 
vac. You do not have, nor did you have an enterocutaneous or colocutaneous fistula. Therefore, this NPWT 
pump is 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 NPWT pump have been met. Therefore, we decided that the Plan has to pre-
approve a negative pressure wound therapy (NPWT) pump.  
 
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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for the single vision lenses described by code V2100. We 
decided that the Plan does not have to hold you harmless for the anti-reflective coating described by code 
V2750.  
 
You asked the Plan to hold you harmless for the single vision lenses described by code V2100, and the anti-
reflective coating described by code V2750 for eyewear purchased on July 13, 2022. You say that you feel that 
the coverage for this eyewear was not correctly processed. The Plan says that this was processed correctly, and 
no additional payment is required. 
 
We decided that the Plan has to hold you harmless for the single vision lenses described by code V2100.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. However, your Plan provides coverage in full for standard lenses.  
 
The file as submitted does not show that you had exhausted the eyewear benefit prior to this purchase. The 
lenses billed are covered as per your contract. The Plan has not provided adequate evidence showing that these 
have been paid in full as described in your contract. Therefore, we decided that the Plan has to hold you 
harmless for the single vision lenses described by code V2100.  
 
We also decided that the Plan does not have to hold you harmless for the anti-reflective coating 
described by code V2750. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. While your Plan does offer a supplemental benefit for routine eyewear, anti-reflective coating is 
explicitly excluded from coverage. Therefore, we decided that the Plan does not have to hold you harmless for 
the anti-reflective coating described by code V2750. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee's diagnosis is not listed for home coverage. 
 
The Plan follows Medicare rules. Medicare rules state that IVIG may be covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gamunex-C. Our reviewer says that the 
enrollee dose not meet criteria for Gamunex-C intravenous immune globulin. Our physician reviewer found the 
enrollee has a myopathy. They do not have a primary immune deficiency disease as defined by the coverage 
article for which the administration of intravenous immune globulin (IVIG) in the home setting would meet Medicare Part B criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Gamunex-C.