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

 
We decided that the Plan does not have to pre-approve infusion therapy services. 
 
You asked the Plan to pre-approve infusion therapy services. 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 infusion therapy services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided and the Medicare-approved major drug 
compendia there is no documentation that the Botox injections at issue in this case meet all Medicare criteria 
for medically reasonable and necessary and safe and effective for the enrollee. Review of the Medicare-approved major drug compendia does not show that diabetic gastroparesis is a medically accepted indication 
for use of Botox, as defined by Medicare criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infusion therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve infusion therapy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Botox injections provided on June 30, 2023. 
 
You asked the Plan to pay for Botox injections. You say that you are disappointed the Botox injections were 
denied and believe they should be considered medically necessary. The Plan denied your request. The Plan 
says the enrollee did not meet the LCD medical necessity criteria for Botox injections for TMJ. 
 
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 to pay for Botox injections. Our reviewer says that the 
Botox injections received are do not meet the criteria necessary for approval. Our physician reviewer found the 
Botox injections received are not FDA approved for the enrollee's diagnosis; The use of Botox for 
temporomandibular joint (TMJ) pain is supported by one of the major drug compendia if the enrollee's pain is 
considered to be chronic and the dosage administered follows the guidelines; However, the records provided do 
not document chronic TMJ pain, the dose of Botox given or that it was administered with electromyographic 
guidance to the masseter and temporalis muscles. The use of Botox for this enrollee's condition does not meet 
Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee due to lack of 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pay for Botox injections provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on October 27, 2021. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on October 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on March 19, 2023. 
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says with the 
information the Plan has, the Plan cannot determine how the member came to the servicing provider, whether 
the billed services were actually performed, or that the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the duplex scan have been met. 
Therefore, we decided that the Plan does not have to pay for a duplex scan provided on March 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT gene panel provided on January 11, 2023. 
 
You asked the Plan to pay for the Tempus xT gene panel. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that NGS testing is only covered under certain 
medical indications. 
 
We find that the panel testing has not been FDA approved or cleared as a companion diagnostic. 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 the Tempus xT gene panel provided on January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223 
and 99233) rendered from May 2, 2023, to May 10, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
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 provided documentation does 
not sufficiently support these codes. The documentation from these dates describes a patient presenting with 
diarrhea and being treated for colitis with improvement on antibiotics and fluids. Although the history and 
examination documentation were appropriate, the documentation did not support a high level of decision 
making, as the enrollee was improving on treatment. The enrollee was not unstable, and didn't require any 
significant treatment changes for these dates. Additionally, the records did not support that the encounters were 
75+ or 50+ minutes, respectively, in duration to justify either CPT 99223 or CPT 99233. 
 
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 evaluation and management services (procedure code 99223 and 99233) rendered from May 2, 
2023, to May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management provided on July 5, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for evaluation and management. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee has no out-of-network benefits. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for evaluation and management provided on July 5, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found given the 
improvement and resolution of the bleeding further treatments do not meet coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy (99183).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 21089 rendered on March 6, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedures shall be reported with the most comprehensive code that describes the services 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 21089 is "Unlisted maxillofacial prosthetic procedure." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 21089 is not supported. 
The record does not contain a description of an unlisted maxillofacial prosthetic procedure. The record stated that a prefabricated tongue depressing and mouth opening stent was delivered to the enrollee. There is a more 
appropriate way to report this 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 procedure code 21089 rendered on March 6, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided on July 17, 2023. 
 You asked the Plan to pay for ambulance transportation services. You say that the transportation provided was 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transportation services provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy evaluation provided on May 10, 2023. 
 
You asked the Plan to pay for physical therapy evaluation. You say that you are requesting reconsideration for 
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 physical therapy 
evaluation provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 26, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mycophenolate. 
 
You asked the Plan to pre-approve Mycophenolate. 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 Mycophenolate.  Benefits for Mycophenolate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide test strip (200 strips per 50 days). 
 
You asked the Plan to pre-approve Accu-Chek Guide test strip (200 strips per 50 days). You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested amount of strips 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 Accu-Chek Guide test strip (200 strips 
per 50 days). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is on metformin and amaryl. The 
documentation shows that the enrollee checks blood glucose sugars frequently. The enrollee's a1c is 6.9%. The 
documentation does not support that the enrollee is using insulin. There is also no log sheet showing how often the enrollee checks and most importantly no statement from the enrollee's doctor as to why the enrollee needs 
to check blood glucose sugars four times per day. Therefore, the enrollee does not meet criteria for the 
requested number of strips. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek Guide test strip (200 strips per 50 days) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Guide test strip (200 strips per 50 
days).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on July 20, 2023. 
 
You asked the Plan to pay for telehealth visit. You say that you are requesting an appeal regarding the denial of 
telehealth services for no prior authorization. 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 telehealth visit provided 
on July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on May 24, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tenotomy, open, tendon flexor provided on May 22, 2023. 
 
You asked the Plan to pay for tenotomy, open, tendon flexor. You say that you were unaware that there was a 
$2,500 limit on coverage when out of state. The Plan denied your request. The Plan says when an enrollee 
receives medically necessary services outside the state of Idaho but within the United States and its territories 
coverage is limited to $2,500 each calendar year. Based on claims history the enrollee has met this limit.  
 
The Plan covers a Convenience Care benefit, which has a maximum of $2,500 each calendar year. 
 
We looked at the file and the Plans rules. The file shows that you have met the Convenience Care benefit 
limit. Therefore, we decided that the Plan does not have to pay for tenotomy, open, tendon flexor provided on 
May 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 11, 2023, to  
June 29, 2023.  
 
You asked the Plan to pay for the psychotherapy. You say that there is no issue with coding or the provider. 
The Plan denied your request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
 We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
May 11, 2023, to June 29, 2023.