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

 
We decided that the Plan does not have to pre-approve a thighplasty procedure and adjacent tissue transfer. 
 
You asked the Plan to pre-approve a thighplasty procedure and adjacent tissue transfer. You say that the 
enrollee has a rash due to the excess skin. The Plan denied your request. The Plan says this 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 a thighplasty procedure and adjacent 
tissue transfer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has weight loss after 
bariatric surgery. The record indicates the presence of intertrigo but does not include documentation of the 
failure of conservative therapy or the existence of functional impairment. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 thighplasty procedure and adjacent tissue transfer have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a thighplasty procedure and adjacent tissue 
transfer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service March 21, 
2023.  
 
You asked the Plan to pay for procedure code 76641. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service March 21, 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 additional routine transportation trips. You say that you need additional 
transportation rides to receive kidney dialysis treatment. The Plan denied your request. The Plan says you have 
exhausted the maximum benefit of 48 one-way trips per year. 
 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 48 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint device. 
 
You asked the Plan to pre-approve a Sprint device. You say that this procedure will help the enrollee. The Plan 
denied your request. The Plan says the Sprint device has not been shown to improve the health of patients with 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Sprint device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for back pain and 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 a Sprint device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sprint device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the total electric hospital bed and mattress 
(E1399) purchased February 11, 2023. 
 
You asked the Plan to reimburse you for the total electric hospital bed and mattress. You say that you are 
appealing this claim because the equipment you purchased serves the purpose for which the doctor ordered. 
The Plan denied your request. The Plan says the item was purchased from a provider that does not participate 
with Medicare. A total electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. The 
rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Also, review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the 
total electric hospital bed and mattress (E1399) purchased February 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service December 10, 
2022.  
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not payable as billed. Specifically, code 99223 is an inpatient evaluation and 
management service that was billed with place of service 21. The documentation shows that the enrollee was 
registered in an outpatient hospital status for this date of service. This means this code is inappropriate to be 
billed for this date of service. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99223 for date of service December 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary to treat the 
enrollee's condition. 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 Trulicity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the device is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the CardioMEMS device has been determined to be 
of uncertain value in the most recent guidelines and carries a risk of significant complications including death 
and severe pulmonary artery injury. The CardioMEMS device at this point should only be approved for 
enrollees enrolled in a clinical trial. There is no indication that this enrollee is enrolled in a clinical trial of the 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has recurrent congestive heart failure (CHF). The CardioMEMS device 
was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in 
the pulmonary artery to allow measurement of pulmonary artery pressure in the management of enrollees with 
CHF. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in enrollees in whom the CardioMEMS system was implanted, reflecting an enrollee 
population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies 
remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In 
addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in enrollee management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289, C2624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test (81529) provided on 
December 13, 2022, by an out-of-network (OON) provider.   
You asked the Plan to pay for the genetic testing. You say that your claim for the DecisionDx-Melanoma test in 
error and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says the 
DecisionDx-SCC is not a covered benefit because this test has not been approved by MolDX as meeting 
Medicare's reasonable and necessary requirement. 
 
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 the DecisionDx-Melanoma test (81529) provided 
on December 13, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq and Kanjinti. 
 
You asked the Plan to pre-approve Tecentriq and Kanjinti. You say that the requested drugs include 
molecularly directed therapy supported by clinical and pre-clinical evidence and could potentially prolong the 
enrollee's survival while optimizing their quality of life. The Plan denied your request. The Plan says the 
requested combination does not meet off label indication.  
 
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 Tecentriq and Kanjinti. Our reviewer 
says that the requested drugs are not medically necessary. Our physician reviewer found the requested use of the requested drugs is not FDA-approved for the enrollees diagnosis. The use of the requested drugs is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq and Kanjinti. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Tecentriq and Kanjinti.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service February 2, 
2023, to March 3, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 2, 2023. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services for date of service 
February 2, 2023, to March 3, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services billed with diagnosis code N17.9 rendered 
from March 16, 2022, to March 21, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the Payment Integrity post-service post-
pay clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 DRG 464. 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 the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee had a documented acute decrease in kidney function, meeting criteria for a diagnosis code of 
N17.9. Thus, the records more support DRG 464 rather than DRG 465. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services billed with diagnosis code N17.9 rendered from March 16, 2022, to March 21, 2022.  
 
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 pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance including arthrography when performed (27096). 
 
You asked the Plan to pre-approve an injection procedure. You say that you are requesting reconsideration 
because you are in a lot of pain, and you have tried therapy. You need injections as soon as possible due to 
numbness and tingling. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show that you have pain, but not that it is related to your sacroiliac joint. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an injection procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you had a previous sacroiliac (SI) joint injection on March 3, 2022; the notes say that 
you had "less than 50% improvement" in pain relief. There is tenderness over the SI joint but no documentation 
of further physical exam diagnostic testing. The LCD requires documentation of 3 diagnostic maneuvers of the 
SI joint. The LCD also requires greater than 50% improvement in pain for at least 2 months. Therefore, the 
request is deemed not medically reasonable and 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 an injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
including arthrography when performed (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6219 billed for date of service February 8, 2023. 
 
You asked the Plan to pay for code A6219. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says procedure code A6219 is 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 A6219 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6219 is not separately payable as billed. Based on this information, we decided that Medicare 
rules for coverage of code A6219 have not been met. Therefore, we decided that the Plan does not have to pay 
for code A6219 billed for date of service February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision bariatric surgery and inpatient admission 
(43644, 43281). 
 
You asked the Plan to pre-approve revision bariatric surgery and inpatient admission. 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 the surgical management for the treatment of morbid 
obesity is considered reasonable and necessary for all nationally covered bariatric surgical procedures and 
Laproscopic sleeve gastrectomy when certain conditions are met and recorded in the medical record. 
 
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 revision bariatric surgery and inpatient 
admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record provided is insufficient to support that the enrollee has established a diligent effort to achieve healthy 
body weight with such efforts described in the medical record and certified by the operating surgeon. 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 revision bariatric surgery and inpatient admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve revision bariatric surgery and inpatient admission 
(43644, 43281).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services received December 8, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you were not advised you needed an 
itemized bill. The Plan denied your request. The Plan says the services are not payable as submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in 
clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 
 
We looked at the file and Medicare rules. Review of the file shows that you submitted a superbill, which does 
not provide proof of what you paid towards the services received. An itemized bill is necessary. Without this 
necessary documentation, the Plan cannot reimburse you for the correct amounts. Based on this information, 
we decided that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we 
decided that the Plan does not have to pay for the chiropractic services received December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 5, 2022. 
 
You asked the Plan to pay for the services. 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 an Excludes1 note indicates that the code 
excluded sould never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes A41.9 and 
R78.81. Diagnosis code A41.9 has an Excludes1 note and cannot be billed with diagnosis code R78.81. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on October 5, 2022.