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

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service January 19, 
2023. 
 You asked the Plan to pay for procedure code 99214. The Plan denied your request. The Plan says payment for 
code 99214 is bundled into payment for code 96365. 
 
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 99214 
is a column II code to column I code 96365. This claim 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 99214 billed for date of service January 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) with an allergist/immunologist to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you must receive your care from a network 
provider. There are in-network providers available for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99213) with an allergist/immunologist to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 4mg orally disintegrating tablets. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee's appetite has been up and down, 
due to the recent death of their spouse, causing nausea and vomiting. 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 Ondansetron 4mg orally 
disintegrating tablets.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that anesthesia services are covered under the 
medical portion of the plan. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 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 
99100 billed for date of service October 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from December 1, 2022, 
to December 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims require one of three Q codes 
and a HIPPS code.  
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required HIPPS 
code and one of three Q codes. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered from December 1, 2022, to December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test results inform treatment decisions. The 
Plan denied your request. The Plan says the test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. tests must undergo an application and technical assessment process 
through the Molecular Diagnostics (MolDX) contractor. MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. The test at issue, the 
DecisionDx-SCC has been determined to be not covered. 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 lab testing billed for date of service February 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure.  
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this device is the best next step in 
the treatment plan to alleviate the enrollee's symptoms and debilitating pain. The Plan denied your request. The 
Plan says interspinous process fusion devices are not proven and medically necessary when used as stand-alone 
lumbar vertebral fusion procedure. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Minuteman procedure is experimental. More research is needed 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sucraid. 
 
You asked the Plan to pre-approve Sucraid. You say that you are requesting reconsideration of the denied 
authorization. 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 Sucraid.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service January 6, 
2023. 
 You asked the Plan to pay for procedure code 11720. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 11720 is bundled into payment for 
code 11719. 
 
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 11720 
is a column II code to column I code 11719. This claim 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 11720 billed for date of service January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Shock Absorption Pylon (L5988). 
 
You asked the Plan to pre-approve the Shock Absorption Pylon . You say that the item is medically necessary. 
The Plan denied your request. The Plan says that the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Shock Absorption Pylon . Our 
reviewer says that the item is medically necessary. Our physician reviewer found the prescribing physicians 
note, the enrollee's K3 level, and gives concrete reasons for her treatment plan specific to the enrollees high-
level of function, which necessarily includes the need for additional vertical shock absorption in activities such 
as hiking and lawn 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 the Shock Absorption Pylon have been met. Therefore, we decided that the Plan 
has to pre-approve the Shock Absorption Pylon (L5988).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
With additional time in the current setting, clinical stability can 
be ensured such that the appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(A4239, E2103) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested provider is the only one in 
your area that can provide the CGM and supplies. The Plan denied your request. The Plan says you must 
receive your medical services and items from a network provider. There are in-network providers who can 
provide the requested CGM and supplies. 
 
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 
a continuous glucose monitor (CGM) and supplies (A4239, E2103) 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 a Freestyle Libre 2 Sensor.  
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. 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 must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 Sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infraumbilical panniculectomy (15830), and 
extensive removal of extra skin and tissue of abdomen (15837). 
 
You asked the Plan to pre-approve the surgical services. You say that the enrollee reports frequent abdominal 
pain and constipation. You also say that current evidence-based research has proven that repair of the 
abdominal muscles at the same time of the hernia repair will allow the enrollee to have a complete resolution of 
symptoms and prevent reoccurrence of hernia. The Plan denied your request. The Plan says this procedure is 
considered cosmetic. The Plan also says that cosmetic procedures are not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is considered 
medically reasonable and necessary when the pannus or panniculus hangs below the level of the symphysis 
pubis causing chronic intertrigo that consistently remains refractory to appropriate medical therapy over a 
period of three months. 
 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 surgical services. Our reviewer says 
that the requested surgical services are not medically necessary. Our physician reviewer found the record 
provided does not document the presence of functional impairment in the activities of daily living or chronic 
intertrigo refractory to conservative treatment due to a pannus. Therefore, the reviewer found that the requested 
surgical services are 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an infraumbilical panniculectomy (15830), and extensive removal of extra skin 
and tissue of abdomen (15837).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the item is 
necessary. The Plan denied your request. The Plan says the enrollee has a power wheelchair that is less than 5 
years old. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for multiple injuries if they do 
not begin rehabilitation right away. You also say the hospital does not offer the level of rehabilitation the 
enrollee needs to return home safely. The Plan denied your request. The Plan says admission to an IRF is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J1644 billed for date of service January 5, 
2023. 
 You asked the Plan to pay for procedure code J1644. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code J1644 is bundled into payment for code 37223. 
 
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 J1644 
is a column II code to column I code 37223. This claim 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 J1644 billed for date of service January 5, 2023.