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

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections.. You say that they forgot to send in magnetic 
resonance imaging pictures at first, but they sent them. The Plan denied your request. The Plan says this request 
cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections (ESIs) will be considered 
medically reasonable and necessary when the three (3) requirements listed in the Medicare rules section of this 
letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injections. Our 
reviewer says that you do not meet the coverage criteria for epidural steroid injections. Our physician reviewer 
found there is no radiographic evidence of disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal, or central spinal stenosis. There was no medical documentation 
of failure to respond to four (4) weeks of noninvasive conservative care or acute herpes zoster refractory to 
conservative management where a four (4) week wait is not required. Our reviewer also found that you do not 
have a condition which is indicated for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D3 testing (82306) provided on August 10, 
2022. 
 
You asked the Plan to pay for the Vitamin D3 testing. You say that you feel this testing was medically 
necessary and should therefore be covered. The Plan denied your request. The Plan says screening tests are not 
covered under your benefits. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 The test at issue in this appeal, the Vitamin D3 testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the Vitamin D3 testing (82306) provided on August 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 20, 2022, 
to March 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 20, 2022, to 
March 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient office visit (99204) with a trauma 
specialist to be rendered by an out-of-network (OON) provider. 
 You asked the Plan to pre-approve an outpatient office visit with a trauma specialist. You say that you would 
like to see a trauma surgeon, and do not want to feel as though you are not being heard by your current 
provider. The Plan denied your request. The Plan says there are available in-network providers that can render 
needed services for you. The Plan also says you do not need a trauma specialist or higher level of care since 
treatment options are available at the community level and within the network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient office visit with a trauma 
specialist. Our reviewer says that an outpatient office visit with an OON trauma specialist is not medically 
reasonable and necessary. Our physician reviewer found the record indicates that you had a fractured tibia after 
a fall. The record provided indicates that the Plan has network providers that are available and capable to 
provide the necessary care for you. Our reviewer found that the elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that 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 an outpatient office visit with a trauma specialist have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an outpatient office visit (99204) with a trauma 
specialist to be rendered by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 99231. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99231 is bundled into payment for code 99232. 
 
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 99231 
is a column II code to column I code 99232 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99231 billed for date of service July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyndamax. 
 
You asked the Plan to pre-approve Vyndamax. You say that you believe the enrollee's diagnosis of cardiac 
amyloidosis is contributing to their shortness of breath. You also say that you have prescribed Vyndamax daily. 
The Plan denied your request. The Plan says Vyndamax is a self-administered drug, and does not fall under 
Part B coverage. 
 
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 Vyndamax.  
 
  Benefits for Vyndamax may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to 
May 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that a Notice of Admission was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to May 2, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary payer's 
explanation of benefits was not received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a ventilator is imperative to the enrollee's health 
and is supported by the records provided. The Plan denied your request. The Plan says the requested device 
would be used in a bi-level positive airway pressure (BiPAP) mode that could be provided with a BiPAP 
device with average volume-assured pressure support (AVAPS) added to assure adequate tidal volumes. 
 
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. 
 
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 ventilator. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically 
necessary. The enrollee has a history of COPD and was recently hospitalized with shortness of breath and 
pneumonia. Arterial blood gas (ABG) was consistent with acute hypercarbic respiratory failure. There are no pulmonary function tests to confirm COPD and assess severity. There is no ABG done while stable to 
document chronic carbon dioxide (CO2) retention. If the enrollee does have chronic CO2 retention, they may 
benefit from BiPAP with AVAPS during sleep as an outpatient. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Bupivacaine (J3490) provided on July 25, 2022. 
 
You asked the Plan to pay for Bupivacaine. The Plan denied your request. The Plan says that this is not 
covered. 
 
The Plan must follow Medicare rules. 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support that this service is not covered. This means that the 
Plan has not provided a valid reason for denying payment of the Bupivacaine. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for Bupivacaine (J3490) provided on July 25, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0730 billed for date of service June 5, 2022. 
 
You asked the Plan to pay for procedure code E0730. You say that you disagree with the Plan's denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code E0730 is 1. The MAI value for this code is 3. You billed 1 unit of this code 
and another 1 unit that was previously paid, exceeding the MUE. You did not provide all the required evidence 
showing that the excess units were actually provided, were correctly coded, and were medically necessary. 
Based on this information, we decided that Medicare rules for coverage of procedure code E0730 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code E0730 billed for date of 
service June 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on April 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 95822 26 (1 Unit) remains 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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 95822 was the best code to use in this clinical situation. The technical report does indicate that an EEG 
was performed. However, this code is not supported as the enrollee was not in a coma or sleep. There are 
typically more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813).   
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 an electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on 
April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 16, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product (VIA Disc procedure) (0627T). 
 
You asked the Plan to pre-approve VIA Disc procedure. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested 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 VIA Disc procedure. Our reviewer says 
that the requested VIA Disc procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental and investigational. Therefore, 
the reviewer found that the VIA Disc procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product (VIA 
Disc procedure) (0627T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69210 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 69210. You say that the records show medical necessity. 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 cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 69210 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 69210 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 69210 billed for date of service May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the application of pain management is 
essential to prevent the enrollee from going into shock. You say that the claim should be reviewed and 
reconsidered for payment. The Plan denied your request. The Plan says procedure code 99053 is considered 
bundled and 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs provided on February 25, 2022. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are 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 CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, code J3490 was billed on the 
same date of service as a surgery procedure. Without an appropriate modifier, this code is considered part of 
the global surgery period for the surgery procedure. Based on this information, we decided that Medicare rules 
for coverage of the unclassified drugs have not been met. Therefore, we decided that the Plan does not have to 
pay for the unclassified drugs provided on February 25, 2022.