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

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December .
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 August 5, 2022. 
 
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 August 
5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy 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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that the Plan's required drug(s) would 
likely be less effective and/or likely have adverse effects 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on October 18, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test is covered by Medicare. The Plan 
denied your request. The Plan says tests must be approved by the MolDX program in order to be eligible for 
Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom manual wheelchair/base (K0008). 
 
You asked the Plan to pre-approve a custom manual wheelchair/base. You say that the enrollee is wheelchair 
dependent and has paralysis due to medical barre syndrome and maneuvers. She has a very old wheelchair that 
is not optimal, with multiple repairs and is needing a replacement for mobility. You are requesting 
reconsideration. The Plan denied your request. The Plan says the requested wheelchair is not medically 
necessary because the documentation does not support that a custom wheelchair base is required over one of 
the standard wheelchair bases and appropriate accessories given the documentation supports the need for a 
K0005 wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a custom manual wheelchair/base. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a medical history of Guillain-Barre Syndrome, pituitary 
adenoma, hyperlipidemia, hypothyroidism, and osteoporosis. The enrollee is independent with her daily 
activities and non-ambulatory. She performs self-catheterization for bladder management. The enrollee has 
impaired sensation and can perform pressure relief. She is noted to have range of motion that is within 
functional limits in the upper extremities, but decreased strength at the shoulders. The enrollee is non-
ambulatory and cannot use a cane or walker for mobility. She has lower extremity paraplegia due to Guillain-
Barre syndrome as well as neurogenic bladder. The enrollee requires a manual wheelchair for mobility and 
performing her daily activities. Her current manual wheelchair is 19 years old and in disrepair. She has 
impaired upper extremity strength at the shoulders and cannot functionally propel a standard or lightweight 
manual wheelchair. While she requires an ultralight weight manual wheelchair this should be achievable with 
standard ultralight weight chair (K0005) given her diagnosis and condition. There is no documented need for 
the degree of modification required for a code of K0008. Therefore, the ultralight weight manual wheelchair 
with code (K0008) is not medically 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 a custom manual wheelchair/base have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a custom manual wheelchair/base (K0008).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the supplemental benefits. You say that the services are necessary. The Plan 
denied your request. The Plan says you do not meet criteria for this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplemental benefits have not been met. Specifically, we have confirmed that you do not 
require intensive care management. The medical records provided do not show a physician assessment of you 
having had two (2) or more inpatient admissions in the last 60 days OR having had three (3) or more 
emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have to pre-approve 
SSBCI.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 27, 
2022. 
 
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 provider is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on November 10, 2022. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus xF testing provided on November 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service November 1, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services related to the transcatheter 
aortic valve replacement provided on October 12, 2022, to October 13, 2022. 
 
You asked the Plan to pay for inpatient hospital services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim does not include the clinical trial 
number as required. 
 
The Plan must follow Medicare rules. Medicare rules say that as of January 1, 2014, providers must report the 
clinical trial number for services covered under CED, in value code D4.  
 
We looked at the file and Medicare rules. We find that the services rendered are covered under CED. The claim 
does not include value code D4. Based on this information, we decided that Medicare rules for coverage of 
inpatient hospital services provided have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services related to the transcatheter aortic valve replacement provided on October 
12, 2022, to October 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00142) billed for date of service July 18, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says that payment for code 00142 is bundled into payment for another 
code. 
 
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. Specifically, the Plans denial states that payment for code 00142 is bundled into 
payment for another code. The Plan has not specified the other code at issue nor provided documentation that 
any code other than 00142 has been billed for the same date of service. It is the Plans responsibility to 
substantiate its denial with evidence. In this case, the Plans denial has not been substantiated, so we must find 
in your favor. Therefore, we decided that the Plan has to pay for anesthesia services (00142) billed for date of 
service July 18, 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 pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that the enrollee only has one chair and 
is in dire need of these repairs. The Plan denied your request. The Plan says the requested repairs cannot be 
covered under the Medicare plan. 
 
The Plan must follow Medicare rules. Medicare rules say that f the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
 
 
 
 
 We looked at the file and Medicare rules. Specifically, the Plan does not have to cover repairs when the sum 
total cost of repairs exceeds the cost of replacing the item. Based on this information, we decided that Medicare 
rules for coverage of power wheelchair repairs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on September 
27, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the claim was submitted to Medicare Part B in 
error. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until October 14, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the subsequent hospital care (99232) provided on September 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 20, 2022, 
to October 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. 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 September 20, 2022, to 
October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87632, 87633, 0115U, 0202U, 0223U, 0225U) 
provided on July 4, 2022. 
 
You asked the Plan to pay for lab services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87632, 87633, 0115U, 0202U, 0223U, 0225U) 
provided on July 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for August 15, 2022. 
 
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 code 99223 is not supported by the submitted documentation. 
 
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 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 these services. Our reviewer says that procedure code 99223 
is not supported by the submitted documentation. Our reviewer found that the enrollee presented to the 
emergency department on August 15, 2022 with right ear pain. He was evaluated and diagnosed with right 
otitis media that required treatment with intravenous (IV) antibiotics. The evaluation and management code billed requires a comprehensive history, a comprehensive examination and medical decision making of high 
complexity. However, the medical records submitted did not support a comprehensive history.The submitted 
records do not support that there was a comprehensive history. The records did support that there was a 
comprehensive exam and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. 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 code 99223 billed for August 15, 2022.