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

 
We decided that the Plan does not have to pay for procedure code 99203-25 billed for date of service May 26, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the office visit was medically necessary. The 
Plan denied your request. The Plan says the code cannot be separately reimbursed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99203-25 is not supported. The file shows that c ode 99203 was billed with minor 
procedure code 36561. The records do not show that code 99203 was a separately identifiable evaluation and 
management service. 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 
99203-25 billed for date of service May 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an ILR in this enrollees 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal tract imaging (91110). 
 
You asked the Plan to pre-approve a gastrointestinal tract imaging. The Plan denied your request. The Plan says 
the requested procedure does 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 a gastrointestinal tract imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no lab results were provided to support either iron deficiency or anemia. 
Further, no recent complete colonoscopy has been performed since 2019, and those results were not provided. 
Our reviewer also found that medical necessity for a capsule endoscopy, for the indication of IDA is not met 
without negative recent esophagogastroduodenoscopy and colonoscopies that together respectively have 
excluded bleeding sites from the upper and lower gastrointestinal tracts. 
 
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 gastrointestinal tract imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a gastrointestinal tract imaging (91110).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
provided September 1, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the continuation of SNF is not medically necessary, and the enrollee's needs can be 
met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you no longer qualifies for SNF coverage. You do not have documented skilled 
nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care provided September 1, 2023, forward.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Breast Cancer Index billed for date of service March 21, 2023. 
 
You asked the Plan to pay for the billed service. You say that the test is a valid molecular assay. The Plan 
denied your request. The Plan says that the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 81518 is supported. Per billing guidelines, code 81518 is the appropriate code to use for 
the test provided. Based on this information, we decided that Medicare rules for coverage of the billed service 
have been met. Therefore, we decided that the Plan has to pay for the Breast Cancer Index billed for date of 
service March 21, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 43239 billed for date of service April 17, 2023. 
 
You asked the Plan to pay for the billed code. You say that there are no code edits for codes 43237 and 43239. 
The Plan denied your request. The Plan says that only code 43237 is payable when billed with code 43239. 
 
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 looked at the file and the rules. The file shows that multiple endoscopy codes, 43237 and 43239, were 
billed on the same date of service. The records show that code 43237 was paid. The file does not show that the 
difference between the next highest code (43239) and base code (43235) was paid. Based on this information, 
we decided that Medicare rules for coverage of the billed code have been met. Therefore, we decided that the 
Plan has to pay for procedure code 43239 billed for date of service April 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc allograft intervertebral disc augmentation 
procedure (0627T). 
 
You asked the Plan to pre-approve the service. You say that you have completed all non-invasive treatments 
with little to no relief and is still experiencing considerable pain.  The Plan denied your request. The Plan says 
the VIA Disc allograft intervertebral disc augmentation is not medically necessary. The Plan says intradiscal 
procedures are not supported by research.  
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested VIA Disc allograft intervertebral disc augmentation procedure 
is 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc allograft intervertebral disc augmentation procedure (0627T).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for AAA (76706) provided on March 10, 2023. 
 You asked the Plan to pay for the ultrasound. You say that medical records submitted supports procedure code 
76706 and should be paid. The Plan denied your request. The Plans says that the coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a one-time ultrasound screening for AAA is 
covered when the criteria listed in the Medicare rules section are met. 
 
We reviewed the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have not been met. Specifically, the medical record does not show the enrollee has a 
family history of AAA. Also, there is no documentation that the enrollee has smoked at least 100 cigarettes in 
his lifetime. Therefore, we decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real 
time with image documentation, screening study for AAA (76706) provided on March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positive airway pressure (PAP) therapy supplies to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PAP therapy supplies. You say that you have been getting supplies from the 
requested provider for several years. The Plan denied your request. The Plan says you must receive your care 
and supplies from a network provider. The requested provider is no longer an in-network provider with your 
Plan. 
 
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 
positive airway pressure (PAP) therapy supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a freestyle libre 3 continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as they are medically 
necessary, and you disagree with the denial. The Plan denied your request. The Plan says that the items are 
excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our physician reviewer 
found that the enrollee meets the clinical requirements to be approved for the items based on the enrollee's 
insulin use. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of the CGM have been met. Therefore, we decided that the Plan has 
to pre-approve a freestyle libre 3 continuous glucose monitor (CGM) sensor.  
 
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 pay for the services (99223, 99233) provided from March 15, 2023, 
to March 17, 2023. 
 
You asked the Plan to pay for the 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. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit". The CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 99223 
and 99233 is not supported by the records provided. Our reviewer found that the documentation on March 15, 
2023, supports a comprehensive exam, but not a comprehensive history or medical decision making of high 
complexity, so code 99223 is not supported. The documentation on March 16, 2023, and March 17, 2023, 
supports detailed exams, but not detailed histories or medical decision making of high complexity, so code 
99233 is not supported for either date of service. 
 
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 the services (99223, 99233) provided from March 15, 2023, to March 17, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing (0315U) provided on February 23, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the billed code is 
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 0315U is "Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR 
of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 
algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B)". 
 
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 testing. Our reviewer says that the use of code 0315U is 
supported by the records provided. Our reviewer found that the record states that a Decision-DX-SCC was 
performed. This test is defined as qRT-PCR assay of 6 control and 34 discriminant genes (40 total) that uses a 
neural network algorithm comprised of 2 gene expression signatures to classify patients into risk categories. 
The record also contains results stating the results of the test as risk category 2A. This meets the definition of 
code 0315U. 
 
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 testing have been met. Therefore, we decided that the Plan has to pay for the 
testing (0315U) provided on February 23, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure for nasal airway remodeling with 
radiofrequency (30117 and 30801). 
 
You asked the Plan to pre-approve the services. You say that this surgery is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says this device has not been shown to be safe and effective 
for treatment of your 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has nasal obstruction and congestion. There is insufficient 
literature to support the safety and efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules of 
the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VivAer procedure for nasal airway remodeling with radiofrequency (30117 and 
30801).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee needs additional visits for 
maintenance with current living and independence in the community. The Plan denied your request. The Plan 
says the requested services are not reasonable and necessary, and the health plan has no contractual obligation 
to cover services that are not covered by Medicare.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program.  There is no documentation of a recent injury or decline 
in function. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation 
(CCM) device. 
 
You asked the Plan to pre-approve an Optimizer Smart CCM device. 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 an Optimizer Smart CCM device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, I would not consider the CCM system to be 
medically necessary in this 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 an Optimizer Smart CCM device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation (CCM) device.