Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve one (1) destruction by neurolytic agent, paravertebral facet joint
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (CPT
Code 64634). We decided that the Plan does not have to pre-approve one (1) destruction by neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each
additional facet joint (CPT Code 64634).

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not considered medically 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 the services. Our physician reviewer
found based on the Medicare Coverage Policy: Local Coverage Determination (LCD): Facet Joint Injections,
Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34832), the enrollee has been approved
to receive treatment at one level. However, CPT Code: 64634 x2 (Facet Blocks) is not considered medically
necessary and cannot be fully approved.

We decided that the Plan has to pre-approve one (1) destruction by neurolytic agent, paravertebral facet
joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint
(CPT Code 64634).

According to the criteria guidelines, criteria have been met for the approval of one level of 64634 facet joint
treatment, in addition to the one level 64633 already approved. Therefore, we decided that the Plan has to pre-approve
the services.

We also decided that the Plan does not have to pre-approve one (1) destruction by neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each
additional facet joint (CPT Code 64634).

Therefore, we decided that the Plan does not have to pre-approve .

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on June 20, 2020. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because this 
service was the decision for surgery and the -57 modifier was applied. The Plan denied your request. The Plan 
says this service is bundled as a part of the global surgical fee. 
 
The Plan must follow Medicare rules. Medicare rules say that the initial consultation may be billed separately 
only for major surgical procedures.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the initial hospital care have not been met. Specifically, CPT code 11043 is a minor endoscopic 
procedure. This means that the initial consultation may be billed separately and is included in the global 
surgical fee. Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) provided 
on June 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on April 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or provider. 
 
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 has network providers 
available who can provide 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 skilled nursing services provided on April 17, 
2020 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 subsequent nursing facility care (99308) provided on 
January 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that medically necessary services were 
rendered in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for 
non-emergent services rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide 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 subsequent nursing facility care (99308) 
provided on January 20, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power mobility device (K0800).
You asked the Plan to pre-approve the power mobility device. You say that you would like reconsideration
because the member has pressure ulcers on her feet and she requires the scooter to safely maneuver outside the
home. The Plan denied your request. The Plan says the member is mobile in the home with the use of a walker.
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 power mobility device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does reveal that the member has a personal mobility
deficit that impairs participation in MRADLs in the home. The member's mobility deficit is currently helped by
a walker. The documentation is not clear why she would be unable to use a manual wheelchair. The
documentation does not clearly indicate whether she can safely maneuver the power mobility device in the
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 the power mobility device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a group 1 power mobility device (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64493-50, 64494-50, 64495-50) provided on 
April 1, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT codes 64493-50, 64494-50, and 64495-50, is not supported by the records provided. Our coding 
reviewer found that the procedure note only documents CPT codes 64493, 64494, and 64495 were performed 
on the right side. Therefore, modifier -50, bilateral procedure, cannot be verified. 
 
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 (64493-50, 64494-50, 64495-50) provided on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 24, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76377) provided March 
11, 2020. 
 
You asked the Plan to pay for the 3D rendering with interpretation. You say that you are requesting 
reconsideration of the claim based on the enclosed supporting documents. You believe that these documents 
will substantiate your request for additional reimbursement. The Plan denied your request. The Plan says 3D-
rendering with interpretation is integral to the primary surgical procedure and not a separately reimbursed 
service 
 
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 the 
radiology services has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot 
be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
 
 
Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76377) 
provided March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
April 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide 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 subsequent nursing facility care (99308) 
provided on April 29, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0428) provided on June 17, 
2020. 
 
You asked the Plan to pay for ambulance services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed with the correct diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that coding of sequela generally requires two codes 
sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is 
sequenced second. 
 
We looked at the file and Medicare rules. The services at issue were billed with a sequela code, S09.90XS, 
sequenced first on the claim. Based on this information, we decided that Medicare rules for coverage of 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
services (A0425, A0428) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on March 2, 2020 to March 17, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you keep getting charged 
$45 for a follow-up visit. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for each specialist office visit. The total amount you are being 
asked to pay is $90 ($45 x 2 visits = $90). A specialist office visit falls within the physician/practitioner 
services/specialist benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office 
visit provided by a participating provider on March 2, 2020 to March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation. The Plan 
denied your request. The Plan says due to persistent weakness related to medical debility, the enrollee is best 
suited to a slower paced, less intensive therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 documentation does not support that there is a need for an intensive therapy 
program with 3 hours a day and an interdisciplinary approach to rehab care. Our reviewer found that the 
enrollee does not meet the CMS coverage criteria for an IRF admission due to lack medical complexity and 
ability to tolerate therapies. Our physician reviewer also found that the enrollee's rehab needs can be met in an 
alternate, less intense setting such as in a skilled nursing facility. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (01442) provided on December 28, 2019. 
 
You asked the Plan to pay for anesthesia. You say that this should be covered. The Plan denied your request. 
The Plan says anesthesia services are not documented in the 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 01442 is anesthesia for procedures on arteries of knee 
and popliteal area; popliteal thromboendarterectomy, with or without patch graft. 
 
We find that CPT code 01442 is not supported in the medical record. Specifically, there is not an anesthesia 
report or other documentation of this service being performed in the records. Based on this information, we 
decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia (01442) provided on December 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 28, 2019.You asked the Plan to pay for the laboratory services.The Plan denied your request. The Plan says there is no valid referral for this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 Plandid not pre-approve the laboratory services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sodium hyaluronate. 
 
You asked the Plan to pre-approve sodium hyaluronate. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says you do not meet step therapy exception criteria 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 sodium hyaluronate. Our reviewer says 
that based on the medical records provided, you have not tired and failed Orthovisc and Monovisc. Our 
physician reviewer found there is no indication that the plan's required drugs would likely be less effective 
and/or likely have adverse effects 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sodium hyaluronate have not been met. Therefore, we decided that the Plan does not have to pre-approve sodium hyaluronate.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on April 25, 2020. 
 
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 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 74019 and 74022. Code 74019 is a column II code with a 
modifier indicator of 1 when billed with column I code 74022. Code 74019 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
abdomen x-ray rendered on April 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prometheus VDZ testing (vedolizumab testing). 
 
You asked the Plan to pre-approve Prometheus VDZ testing. You say that your doctor recommended this 
testing for you to determine if medication is getting into your circulatory system and giving correct treatment. 
The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this 
testing is experimental/investigational and not covered. 
 
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 Prometheus VDZ testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it has not been demonstrated that Prometheus VDZ testing impacts the management 
and outcomes of patients with ulcerative colitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prometheus VDZ testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Prometheus VDZ testing (vedolizumab testing).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 16, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0627) purchased on June 3, 2020. 
 
You asked the Plan to pay for a seat lift mechanism. You say that you were not able to purchase this item from 
a participating provider. The Plan denied your request. The Plan says items purchased from providers that are 
not enrolled in Medicare are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The item at issue was not purchased from a provider or supplier that 
is enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of 
a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift 
mechanism (E0627) purchased on June 3, 2020.