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

 
We decided that the Plan does not have to pay for the initial hospital inpatient or observation care (99222) 
provided November 2, 2022. 
 
You asked the Plan to pay for  hospital care. You say that the medical records provided support the necessity of 
the services in dispute. 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. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 44970 
provided on November 2, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital inpatient or 
observation care (99222) provided November 2, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210) provided 
March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the extraction was medically necessary to 
prevent the further spread of infection which could have endangered the enrollee's life or vision. The Plan 
denied your request. The Plan says this service is not covered under the Plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical 
removal of erupted tooth (D7210) provided March 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron hydrochloric acid (HCL). 
 
You asked the Plan to pre-approve Palonosetron HCL. You say that the requested Palonosetron HCL is 
medically necessary.  The Plan denied your request. The Plan says the requested Palonosetron HCL is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Palonosetron HCL. Our reviewer says 
that the requested Palonosetron HCL is not medically necessary.  Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of metastatic adenocarcinoma of the lung that has progressed on a 
checkpoint inhibitor. The requested chemotherapy regimen was denied as the regimen contained a checkpoint 
inhibitor. The Food and Drug Administration 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. A drug for supportive use in a chemotherapy regimen is 
not medically necessary if the underlying drug regimen is not approvable for coverage under the cancer 
coverage rules. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Palonosetron HCL have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Palonosetron hydrochloric acid (HCL).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that the requested Yervoy is medically necessary. The 
Plan denied your request. The Plan says the requested Yervoy is not medically necessary. 
 
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 Yervoy. Our reviewer says that the 
requested Yervoy is not medically necessary. Our physician reviewer found the requested use of Yervoy in 
combination with Opdivo and Pemetrexed to be used with Carboplatin is not Food and Drug Administration-
approved for the enrollee's diagnosis of stage 4 adenocarcinoma of the lung with no actionable mutations and a history of disease progression on prior pembrolizumab. The requested use of Yervoy in combination with 
Opdivo and Pemetrexed to be used with Carboplatin for the treatment of the enrollee's diagnosis of stage 4 
adenocarcinoma of the lung with no actionable mutations and a history of disease progression on prior 
pembrolizumab 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 Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93925 and 93978 billed for April 14, 2023. 
 
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 procedure codes 93925 and 93978 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 93925 is duplex scan of lower extremity arteries or 
arterial bypass grafts; complete bilateral study. The definition of code 93978 is duplex scan of aorta, inferior 
vena cava, iliac vasculature, or bypass grafts; complete study. 
 
We find that CPT codes 93925 and 93978 are not supported in the medical record. Specifically, there is no 
documentation of a complete study of both extremities to support code 93925. There is no documentation of 
Doppler-specific information or findings to support code 93978. 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 procedure codes 93925 and 93978 billed for April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 6, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81328, 81335, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 6, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81328, 81335, and 
81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that the enrollee has radiating pain that begins in both 
legs and ends in the bilateral toes. The Plan denied your request. The Plan says a sacroiliac joint injection is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
enrollee does not meet the LCD coverage criteria. Our physician reviewer found that there is no moderate to 
severe low back pain primarily experienced over the anatomical location of the sacroiliac joints between the 
upper level of the iliac crests and gluteal fold. The clinical findings or imaging studies do suggest other 
diagnosed or obvious cause of the lumbosacral pain and there are not at least three positive findings with 
provocative maneuvers. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested Gelsyn-3 is medically necessary.  The 
Plan denied your request. The Plan says the requested Gelsyn-3 is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Gelsyn-3. Our reviewer says that the 
requested Gelsyn-3 is not medically necessary.  Our physician reviewer found the medical records do not show 
failure of a recent course of conservative therapy such as physical therapy or failure of, or contraindication to 
intra-articular glucocorticoid injections. The review has determined that the documentation does not support 
that Gelsyn-3 is medically reasonable or necessary for the enrollee. In addition, the documentation does not 
support that Gelsyn-3 is safe and effective for the 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service April 17, 2023. 
 
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. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We find that CPT code 99223 is not payable as billed. Specifically, this service was billed with a place of 
service 21 (inpatient). The documentation shows that the enrollee was registered outpatient hospital. This 
means it is inappropriate to report this code with place of service 21 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 April 17, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee was started on BiPAP some months ago at a pressure of 10/5 and has been compliant in using the 
device. The enrollee's chronic carbon dioxide (CO2) retention is likely due to the combination of COPD and 
chronic narcotic therapy. The enrollee may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) at a higher inspiratory pressure level. This has not been tried as an outpatient, according to 
the records. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for continuous glucose monitor billed with 
code A4238 for date of service April 25, 2023. 
 
You asked the Plan to pay for supply allowance for continuous glucose monitor. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies provided. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for supply allowance 
for continuous glucose monitor billed with code A4238 for date of service April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided on December 8, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this testing is not 
covered when provided OON. 
 
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 drug testing (G0482) provided on December 8, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 22, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound dressings billed with codes A6252 and A6196 
provided on April 3, 2023, by an out-of-network (OON) provider.  
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 wound dressings billed with codes A6252 and 
A6196 provided on April 3, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes and the shoe inserts provided on 
December 28, 2022, by an OON provider.  
 
You asked the Plan to pay for the diabetic shoes and the shoe inserts. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service was not 
authorized. 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 diabetic shoes and the shoe inserts provided on 
December 28, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of subcutaneous tissue (11042) provided on 
March 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the debridement of subcutaneous tissue. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this procedure is not covered when provided OON 
without prior approval. 
 
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 debridement of subcutaneous tissue (11042) 
provided on March 20, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve routine transportation up to the Plan's 48-trip limit. 
 
You asked the Plan to pre-approve routine transportation. You say that you need transportation to medical 
appointments. The Plan denied your request. The Plan says that the requested number of trips exceeds your 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. The rules say that Medicare health 
plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its 
decision to deny coverage or payment. 
 
We looked at your request, the records in the case file, and the rules. The case file did not include a record of 
the routine trips that have been covered for the enrollee so far this year. Without this information we are unable 
to verify if the requested trips exceed the enrollees benefit. Additionally, the Plan denied coverage indicating 
the enrollee has a 36-trip limit. However, the EOC shows that the enrollee is allowed up to 48 trips per year. 
Based on this information, we decided that the Plans rules for coverage of routine transportation have been 
met. Therefore, we decided that the Plan has to pre-approve routine transportation up to the Plan's 48-trip limit.  
 
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.