Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service October 6, 
2022, to October 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was submitted. The 
Plan denied your request. The Plan says an NOA was not submitted. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. In this case, the documentation provided does not show that an NOA was 
billed as required. 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 the home health care billed for 
dates of service October 6, 2022, to October 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix and Lumakras. 
 
You asked the Plan to pre-approve Vectibix and Lumakras. You say that Vectibix and Lumakras are medically 
necessary in treating the enrollees malignant neoplasm of cardia. The Plan denied your request. The Plan says 
Vectibix and Lumakras are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Vectibix and Lumakras. Our reviewer 
says that the use of Vectibix and Lumakras for the treatment of the enrollee's diagnosis of stage IV esophageal 
cancer/malignant neoplasm of the cardia of the stomach is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found Vectibix 
and Lumakras are not Food and Drug Administration-approved for the enrollee's diagnosis of stage IV 
esophageal cancer/malignant neoplasm of the cardia of the stomach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix and Lumakras have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vectibix and Lumakras.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on July 
26, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had a hole in your crown and it required re-
cementing. You also say that you are requesting your provider be paid for these services and wish to know how 
to proceed in the future. The Plan denied your request. The Plan says your benefit for the requested service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service September 19, 2022. Therefore, 
we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on July 26, 
2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has pre-approved Syfovre. 
 
You asked the Plan pre-approved Syfovre. You say that Syforve is needed to treat geographic atrophy. The 
Plan denied your request. The Plan says that Syforve is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pre-approve Syfovre. Our reviewer says that the Food 
and Drug Administration has stated that the requested drug is indicated for the enrollee's condition and the 
record provided establishes the medical necessity and reasonableness, as defined by Medicare rules. Our 
physician reviewer found the elements of the coverage criteria are satisfied, and the requested services are 
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 Syfovre have been met. Therefore, we decided that the Plan has pre-approved 
Syfovre.  
 
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 subsequent nursing facility care provided on August 09, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. 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 subsequent nursing 
facility care provided on August 09, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (99204) provided on August 9, 2023. 
 
You asked the Plan to pay for an office visit. You say that the surgery billed for this date of service was billed 
in error and the office visit at issue is the correct service. The Plan denied your request. The Plan says that this 
cannot be paid separately from the surgery billed with 27786 on the same sate of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has confirmed that the surgery billed with 27786 did not take place and 
payment for this service was recouped; however, the Plan has not provided any additional reasoning for the 
office visit at issue remaining denied when it is not part of a global surgical package. Therefore, we decided 
that the Plan has to pay for an office visit (99204) provided on August 9, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99284) provided on August 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
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 services. Our reviewer says that the use of code 99284 is 
not supported by the records provided. Our reviewer found that the documentation shows that the medical decision-making was not of moderate complexity. 
 
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 emergency care (99284) provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 28, 2023. 
 
You asked the Plan to pay for the physician services. You say that this is the enrollees primary care provider. 
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 physician services 
provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 25, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. 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 subsequent nursing 
facility care provided on June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service August 11, 
2023. 
 
You asked the Plan to pay for procedure code 92929. You say that the coding was accurate. The Plan denied 
your request. The Plan says procedure code 92929 is considered bundled and 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 procedure code. 
 
We find that procedure code 92929 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
92929 billed for date of service August 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99285) provided on June 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 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 services. Our reviewer says that the use of code 99285 is 
not supported by the records provided. Our reviewer found that a high level of medical decision-making requires 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount and 
complexity of data reviewed, and high risk of complication. The provided records in this case do not document 
2 out of the 3 requirements. 
 
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 emergency care (99285) provided on June 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 15, 2022, to 
March 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 is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, described as 
metabolic encephalopathy. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the documentation describes the enrollee as alert and oriented and at 
her baseline mental status. Also, she had no signs of infection or other metabolic abnormality that could have 
potentially contributed to a worsening mental status. As such, the clinical records do not sufficiently support 
code G93.41 for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 15, 2022, to March 25, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service May 16, 
2023.  
 
You asked the Plan to pay for procedure code 87634. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the billed number of units are not supported by the records as both 
provided and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87634 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
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 87634. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found the laboratory report documents 
procedure respiratory syncytial virus was performed with "not detected" as the result. One unit is supported in 
the laboratory report. However, the additional units billed cannot be verified.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87634 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 87634 billed for date of service May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and chiropractic manipulation (98940 
x 2) provided from July 19, 2023, to July 24, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that you feel you should not be responsible for 
the $55 charge. The Plan denied your request. The Plan says this service is not covered when performed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and chiropractic manipulation (98940 x 2) provided 
from July 19, 2023, to July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation first 15 minutes (D9222) and deep 
sedation each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve the dental services. You say that sedation is necessary for this surgery due 
to the pain and complication of the procedure. The Plan denied your request. The Plan says these services are 
not covered benefits under the enrollee's dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation first 15 minutes (D9222) and deep sedation each subsequent 15-minute increment (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision examination provided on September 08, 2023. 
 
You asked the Plan to pay for the vision examination. You say that you are requesting reconsideration of the 
denied claim. 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 vision examination 
provided on September 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87798, 87801, 87481, 87653, 87641 
and 87500) billed for date of service September 4, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and was billed 
appropriately. The Plan denied your request. The Plan says the service at issue are a laboratory panel which 
was not billed with a single panel code in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87798, 87801, 87481, 87653, 87641 and 87500) billed for 
date of service September 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve a CGM. You say that the Dexcom G7 is necessary because it will improve 
their daily functioning and monitoring of their blood sugar. The Plan denied your request. The Plan says the 
denial of authorization for the CGM is correct, because the medical documentation does not show the Dexcom 
G6 is not meeting the enrollee's medical needs. 
 
The Plan follows Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less than 5 
years. The rules also say that replacement due to wear is not covered during the RUL of the equipment. 
 
  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 continuous glucose monitor (CGM). 
Our reviewer says that the replacement for the CGM coverage criteria was not met. Our physician reviewer 
found that the record indicates that the enrollee has diabetes and received a glucose monitor in 2022. The 
record provided does not establish that the device was lost or irreparably damaged. 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 a continuous glucose monitor (CGM) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom G7.