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

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service July 17, 2022, and July 
18, 2022. 
 
You asked the Plan to pay for code 99233. You did not provide a specific argument for coverage with your 
appeal. The Plan denied your request. The Plan says code 99233 billed for dates of service July 17, 2022, and 
July 18, 2022, is not supported by the medical records. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination 
of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the patient is unstable or has developed a significant complication or a 
significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients hospital 
floor or unit. 
 
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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record for the dates of service in question. Our reviewer found the enrollee was a 
then, 87-year-old male with a history of coronary artery disease status post coronary artery bypass graft and 
percutaneous coronary intervention with permanent pacemaker. The enrollee has atrial fibrillation, 
hypertension, and hyperlipidemia and was admitted status post mechanical fall on July 17, 2022, with a left hip 
fracture. He underwent an intramuscular nail procedure. For the dates of service in question, there were no 
notes provided for billing of procedure code 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 code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service July 17, 2022, and July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 the enrollee was admitted for urinary tract infection and deep vein thrombosis. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled
release vehicle into diseased crevicular tissue, per tooth (D4381), and periodontal scaling and root planing -
four or more teeth per quadrant (D4341) provided on March 2, 2023, and March 9, 2023.

You asked the Plan to pay for the localized delivery of antimicrobial agents and periodontal scaling and root
planing. You say that you have been trying to get an in-network dentist to assist you with your teeth. You also
say that you have medical problems which require you to have regular dental care. The Plan denied your
request. The Plan says the dental services were received from an out-of-network provider and are not covered
by your supplemental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery of antimicrobial
agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for localized delivery of
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided
on

The record shows you received the requested dental services from an out-of-network provider. Though the Plan
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have
to pay for localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular
tissue, per tooth (D4381), and periodontal scaling and root planing - four or more teeth per quadrant (D4341)
provided on March 2, 2023, and March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service April 12, 2022. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the billed service cannot be verified. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records include a laboratory order; however, due to poor quality, the tests which were ordered are 
undetermined. Based on this information, we decided that Medicare rules for coverage of code G0483 have not 
been met. Therefore, we decided that the Plan does not have to pay for code G0483 for date of service April 12, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Golimumab (Simponi Aria) (J1602). 
 
You asked the Plan to pre-approve Simponi Aria. The Plan denied your request. The Plan says based on the 
lack of an indication for using Simponi Aria in patients diagnosed with moderately to severely active 
rheumatoid arthritis not in combination with methotrexate, the off-label denial is upheld. 
 
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 pre-approve Simponi Aria. Our reviewer says that 
Simponi Aria cannot be recommended. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of moderately to severely active rheumatoid arthritis. The record provided does not indicate that the 
requested drug will be given in combination with methotrexate or that methotrexate is contraindicated for the 
enrollee. Our reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. Our physician reviewer also found that 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 Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Golimumab (Simponi Aria) (J1602).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty (67904) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve blepharoplasty with an out-of-network provider. You say that this is 
medically necessary. The Plan denied your request. The Plan says the requested service is available in-network. 
 
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 
blepharoplasty (67904) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 12, 2023, billed 
with procedure code R0070. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service must occur with a clinically required 
service. 
 
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 practitioner services provided have 
been met. Specifically, no medical records have been provided for review. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on January 12, 2023, billed with procedure code R0070.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96365, 96366) provided on February 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 96365 
and 96366 is not supported by the records provided. Our reviewer found that the record states that a continuous 
insulin infusion was performed, with monitoring of blood glucose to guide the infusion. There is a more 
specific code for this procedure. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (96365, 96366) provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you feel that an 
immediate approval of a motorized wheelchair is medically necessary. The Plan denied your request. The Plan 
says the requested service is not medically necessary as your mobility limitations are corrected with a cane 
and/or walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 group 2 standard power wheelchair. 
Our reviewer says that you do not meet the coverage criteria. Our physician reviewer found the documentation 
available for review does not support that you require a power mobility device to accomplish mobility related 
self-care tasks in the home. Our reviewer also found that there is no indication that you are unable to use an 
alternative assistive device. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81295, 81297) provided on August 9, 2022. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81295 is MSH2 (mutS homolog 2, colon cancer, 
nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full 
sequence analysis. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 81295 is 
not supported by the records provided. Our reviewer found that code 81295 is not the best code to report the lab 
tests performed. The record shows that over 51 genes were tested in a genomic sequencing panel. There is a 
more specific code 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 code 81295 have not been met. 
 
In this case, we have also confirmed that code 81297 is a column II code to column I code 81295. 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 the services 
(81295, 81297) provided on August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 provided on March 9, 2023. 
 
You asked the Plan to pay for procedure code 64447. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 64447 is not supported. This code has a bilateral surgery indicator of 1. This means the 
code should be reported with 1 unit of service and modifier 50 (bilateral modifier) or an appropriate anatomical 
modifier (right or left) to be considered for payment. Based on this information, we decided that Medicare rules 
for coverage of code 64447 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64447 provided on March 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grafting of autologous fat harvested by liposuction 
technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate (15773) 
and graft; derma-fat-fascia (15770). 
 
You asked the Plan to pre-approve grafting of autologous fat harvested by liposuction technique to face, 
eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate and graft; derma-fat-
fascia. You say that the services are medically necessary. The Plan denied your request. The Plan says under 
Medicare guidelines, your request is not medically necessary because it is a cosmetic procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 grafting of autologous fat harvested by 
liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less 
injectate and graft; derma-fat-fascia. Our reviewer says that the requested services are not required for the 
prompt repair of accidental injury, or for the improvement of the functioning of a malformed body member. 
Our reviewer found cosmetic surgery performed purely for the purpose of enhancing one's appearance is not 
eligible for coverage. Cosmetic surgery performed to treat psychiatric or emotional problems is generally not 
covered. Corrective facial surgery will be considered cosmetic, rather than reconstructive, when there is no 
functional impairment present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of grafting of autologous fat harvested by liposuction technique to face, eyelids, 
mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate and graft; derma-fat-fascia have 
not been met. Therefore, we decided that the Plan does not have to pre-approve grafting of autologous fat 
harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 
cc or less injectate (15773) and graft; derma-fat-fascia (15770).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on 
November 21, 2022. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on November 
21, 2022.