Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11043 billed for date of service April 20, 
2023. 
 
You asked the Plan to pay for procedure code 11043. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
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 11043 is: Debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. 
 
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 procedure code 11043. Our reviewer says that procedure 
code 11043 does not meet criteria for payment. Our reviewer found that the provided medical documentation does not support procedure code 11043. There is a more appropriate code that can be used for the diabetic foot 
procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 11043 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 11043 billed for date of service April 20, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inpefa. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Inpefa.   
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 physician services (99223, 43262, & 43261) provided on 
October 26, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 for the evaluation and management of a patient, requiring a comprehensive history, a comprehensive examination, and medical 
decision making of 
high complexity. 
 
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 physician services. Our reviewer says that the billed 
services are not supported by the records. Our reviewer found the records submitted don't support a 
comprehensive history and medical decision making of high complexity, so code 99223 is not supported. 
Records do not show that codes 43262 & 43261 were separate and distinct from procedure 43274 which was 
also billed. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223, 43262, & 43261) provided on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(A4239, E2103). 
 
You asked the Plan to pre-approve the dental services. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 
The Plan follows 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 dental services. Our physician 
reviewer found that you are not currently using insulin or have a history of hypoglycemia. The record does not 
indicate that your blood sugar levels are low. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM) and supplies (A4239, E2103).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee needs this as soon as possible. The 
Plan denied your request. The Plan says there is retropulsion and additional pathologies noted on magnetic 
resonance imaging (MRI). 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is only covered if certain 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this surgery. Our physician reviewer found there is no trial of a back brace. 
More conservative measures are 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that this procedure is necessary for the 
enrollee to relieve their symptoms. The Plan denied your request. The Plan says this procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
(LUTS)/benign prostatic hyperplasia (BPH) will be considered reasonable and necessary once per lifetime in 
patients with persistent moderate to severe symptoms despite maximal medical management including 
International Prostate Symptom Score (IPSS) 12, maximum urinary flow rate (Qmax) of 15 mL/s (voided 
volume greater than 125 cc), and failure, contraindication or intolerance to at least three months of 
conventional medical therapy for LUTS/BPH. 
 
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 outpatient procedure. Our reviewer 
says that the request for transurethral waterjet ablation of prostate is not medically necessary. Our physician 
reviewer found the records do not show that the enrollee has a prostate volume of 30-150 cubic centimeters 
(cc) as measured by transrectal ultrasound (TRUS), a maximum urinary flow rate (Qmax) of =15 mL/s (voided 
volume greater than 125 cc), or a body mass index < 42kg/m2. Therefore, the reviewer found that the request 
for transurethral waterjet ablation of prostate 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continuation of skilled nursing is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines because no longer requiring skilled services on a daily inpatient basis and the continuation of SNF. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this device due to 
worsening heart failure. The Plan denied your request. The Plan says CardioMEMS has been determined to be 
of uncertain value with risk of significant complications including death. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634 and 87798 billed for date of service 
March 11, 2023. 
 
You asked the Plan to pay for procedure codes 87634 and 87798. The Plan denied your request. The Plan says 
the claim is not payable as billed. 
 
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 87634 
is a column II code to column I code 87798. Based on the claim submitted, Medicare billing criteria have not 
been met. 
 
Additionally, the documentation submitted does not contain a valid physician order or lab requisition for the 
billed testing (87798). The documentation submitted does not include which laboratory test was 
ordered/requested to validate the billed not otherwise unspecified code. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87634 and 87798 billed for date of service March 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you were told not to drive due to your 
condition. The Plan denied your request. The Plan says routine transportation beyond 72 one-way trips per 
calendar year is not covered by the Plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift chair. 
 
You asked the Plan to pre-approve a power seat lift chair. You say that you need the power seat lift chair 
because it is hard for you to stand up on your own. The Plan denied your request. The Plan says you do not 
require a power seat lift chair per guideline criteria. The Plan also says that you are independent with mobility 
in your home without an assistive device and are independent with all your transfers. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a power seat lift chair. Our reviewer 
says that you do not meet the criteria for coverage. Our physician reviewer found the documentation does not 
indicate that you have severe neuromuscular disease or severe arthritis, or that you are incapable of standing up 
from a regular armchair or any chair in your home. 
 
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 power seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat lift chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization services provided from January 
17, 2023, to January 18, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospitalization services. You say that the inpatient care was 
medically necessary. The Plan denied your request. The Plan says this claim was denied for no prior 
authorization for the inpatient level of care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 hospitalization services. Our 
reviewer says that the post-stabilization care services provided from January 17, 2023, to January 18, 2023, at 
the non-Plan facility were not medically necessary and reasonable Our physician reviewer found the patient 
was stable and appropriate for ambulance transport with monitoring to a Plan facility after the emergency room 
evaluation. The patient was fully evaluated and had mild cystitis with positive urinalysis but no severe features 
of infection such as persistent altered mental status, tachycardia, persistently low blood pressure that did not 
respond to treatment. Our reviewer also found that the treating physician did not document (in the physician 
notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
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 inpatient hospitalization services have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospitalization services provided from January 17, 2023, to 
January 18, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of a deep implant (20680) provided on November 
15, 2022. 
 
You asked the Plan to pay for removal of a deep implant. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says the service at issue was not 
billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure.  
 
 
 
 We looked at the file and Medicare rules. The service at issue is within the 90-day global surgery period of 
code 14310 provided on October 16, 2022. The documentation submitted indicates that the removal of the 
implant was directly related to the surgery provided on October 16, 2022. In addition, CPT code 20680 was not 
billed with a modifier to indicate that this service was distinct from the initial surgery. As such, the billing rules 
for this service have not been met. Therefore, we decided that the Plan does not have to pay for removal of a 
deep implant (20680) provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided on March 
23, 2023. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare. 
 
We looked at the file and Medicare rules. The infusion services provided comprise an OIVIT regime and are 
non-covered. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for infusion services (96365, 
96366, 96521) provided on March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services coded as 99232 performed on 
September 26, 2022.  
 
You asked the Plan to pay for the inpatient services. You say that 99232 should be covered because it is 
supported in the documentation. The Plan denied your request. The Plan says 99232 is denied because it is not 
supported in the documentation. 
 
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 99232 is 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 moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 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 services. Our reviewer says that 
99232 is not supported in the documentation. Our reviewer found code 99232 requires 2 out of 3 of an 
expanded problem focused history, an expanded problem focused examination and moderate level of medical 
decision making. An expanded problem focused history requires a chief complaint, a brief history of present 
illness and a problem pertinent systems review. An expanded problem focused exam requires a limited exam of 
the affected body area and related systems. Medical decision making of moderate complexity requires 2 out of 
3 of multiple diagnoses or management options, a moderate amount and complexity of data reviewed, and 
moderate risk of complication.  
 
Provided records in this case do not document an expanded problem focused history that includes all of the 
required elements: a chief complaint, a brief history of present illness, and a problem pertinent systems review. 
Provided records in this case document a limited exam of the affected body area and related systems. Provided 
records in this case do not document 2 out of 3 of multiple diagnoses or management options, a moderate 
amount and complexity of data reviewed and moderate risk of complication. Records do not document total 
time of the encounter was 35 minutes or more.  
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient services coded as 99232 performed on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac implantable device. 
 
You asked the Plan to pre-approve a cardiac implantable device. You say that the requested cardiac implantable 
device is medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria 
for a cardiac implantable device. 
 
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 cardiac implantable device. Our 
reviewer says that the enrollee does not meet criteria for a cardiac implantable device. Our physician reviewer 
found review of the clinical documents does not show that the enrollee meets implant criteria for defibrillator 
insertion according to current guidelines. In the absence of such documentation, implantation of an automatic 
defibrillator would not be considered medically necessary in the management of 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 a cardiac implantable device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cardiac implantable device.