Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from March 16, 
2021, to April 14, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like to know why this 
claim was denied. The Plan denied your request. The Plan says the non-contracted provider did not submit the 
RAP claim for services for dates of service March 16, 2021, to April 14, 2021 until November 29, 2021. The 
Plan also says that no exception request was submitted to the Plan to waive the 5-day requirement for filing the 
RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from March 16, 2021, to April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on December 6, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says experimental 
or investigational services are 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 pay for an epidural injection. Our reviewer says that 
the requested epidural injection is not considered medically reasonable and necessary in this case.  Our physician reviewer found that the provider is requesting coverage for additional intermittent subarachnoid 
injection of opioid medication through the existing implantable subarachnoid catheter. However, the clinical 
documentation does not support the purportedly performed procedure (code 62320) on 
December 6, 2021. The provided documentation does not contain sufficient information in the medical records. 
Therefore, the review has determined that the requested procedure was 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 an epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pay for an epidural injection provided on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy to treat non-neoplastic nevus (CPT code 
36471). 
 
You asked the Plan to pre-approve the services. You say that this service is supposed to get rid of your varicose 
veins, and you want to have this done. The Plan denied your request. The Plan says the treatment of non-
neoplastic nevus is cosmetic and is denied for lack of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The rules say claims listing the following ICD-10-CM code will be 
considered as cosmetic and denied for lack of medical necessity: I78.1 Nevus, non-neoplastic. The diagnosis 
listed by your provider is I78.1 Nevus, non-neoplastic. Therefore, this is considered as cosmetic and is denied 
for lack of medical necessity. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy to 
treat non-neoplastic nevus (CPT code 36471).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan, thorax, diagnostic; without contrast material 
(CPT code 71250). 
 
You asked the Plan to pre-approve the CT scan. You say that you are really sick and need this service. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our physician reviewer 
found imaging is not supported without results of prior chest imaging for comparison. This is done to see if 
something that was found on prior imaging is now stable, worse, or gone. The provided records do not describe 
these results. The review has determined that the requested CT scan 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT scan, thorax, diagnostic; without contrast material (CPT code 71250).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsatellite instability analysis (81301) BCR/ABL1 
(t(9;22)) (81206) provided on November 21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 microsatellite instability analysis (81301) 
BCR/ABL1 (t(9;22)) (81206) provided on November 21, 2021 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 additional supplies, materials, and clinical staff time 
(99072) provided on February 19, 2021. 
 
  You asked the Plan to pay for the additional supplies, materials, and clinical staff time (99072). You say that 
plans are required to pay non-contract providers at the preferred provider rate when services are not available 
from preferred providers in the service area. You say that the in-network benefits should be honored, and the 
claim processed for payment. The Plan denied your request. The Plan says bundled services are not eligible for 
separate payment. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies, materials, and clinical staff time (99072) have not been met. Therefore, we decided 
that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided 
on February 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (CPT code J0885) and therapeutic, prophylactic, 
or diagnostic injection (CPT code 96372). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows they have tried 
one of the preferred drugs Aranesp or Retacrit and it has not worked, or that they have medical reasons that 
prevent the enrollee from using one of them.  
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 the medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Aranesp or Retacrit. The 
documentation does not support that Aranesp or Retacrit would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Procrit (CPT code J0885) and therapeutic, prophylactic, or diagnostic injection (CPT code 
96372).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (A9270) purchased October 16, 2021. 
 
You asked the Plan to pay for the walker. You say that you had open heart surgery and called the Plan to find 
out what they would pay for and was told the Plan would pay for your walker. Now the Plan is refusing to pay. 
The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (A9270) purchased October 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous access and closure of femoral artery 
(34713) provided on July 27, 2021. 
 
You asked the Plan to pay for the percutaneous access and closure of femoral artery (34713). You say that the 
operative report outlines CPT code 34713 being performed bilaterally. You say that the rules state CPT code 
34713 should be billed on two lines with LT and RT modifiers. The Plan denied your request. The Plan says 
CPT code 34713 has an MUE value of 1 but the provider billed 2 units. 
 
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 34713 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 the 
percutaneous access and closure of femoral artery (34713) have not been met. Therefore, we decided that the 
Plan does not have to pay for the percutaneous access and closure of femoral artery (34713) provided on July 
27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0012M) provided on October 21, 
2021. 
 
You asked the Plan to pay for code 0012M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that CPT codes 
0012M and 0013M for CxBladder are non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (0012M) provided on October 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient clinic visit on October 7, 2021. 
 
You asked the Plan to waive the copayment for Outpatient clinic visit. You say that you feel that you should 
not be responsible for the copayment. The Plan denied your request. The Plan says the benefit applied correctly 
per the members evidence of coverage plan benefit. 
 
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 $350 
copayment for Outpatient clinic visit.  
 
You have been asked to pay a $350 copayment for Outpatient clinic visit. Outpatient clinic visit falls within the 
Outpatient clinic visit 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 Outpatient 
clinic visit on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (K0606) provided on 
September 21, 2021, to November 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 durable medical equipment (K0606) provided 
on September 21, 2021, to November 21, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home health services provided on November 4, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 Home health services provided on November 4, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 
70450) provided on December 21, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered 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, 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 CT scan, head or brain; without contrast material (CPT code 
70450) provided on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on October 18, 2021, billed with code 70450-26. 
 
You asked the Plan to pay for the CT scan interpretation. You say that this should be paid and not bundled with 
other services. The Plan denied your request. The Plan says a valid modifier was not reported to bypass the 
PTP edit. 
 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 the interpretation of the computed tomography (CT) scan of the 
head provided on October 18, 2021, billed with code 70450-26.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil tablets. 
 
You asked the Plan to pre-approve Tadalafil tablets. The Plan denied your request. The Plan says self-
administered medications are not covered. 
 
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 Tadalafil tablets.  
 
  Benefits for Tadalafil tablets 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 26, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CMT; spinal, 1-2 regions (CPT code 98940). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the information received shows that no further clinical benefit can be expected from 
ongoing chiropractic care. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
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 the services. Our physician reviewer 
found the record indicates that you have lumbar subluxation. The record states there is no change in condition, 
indicating maximum benefit has been achieved and further therapy would be considered maintenance therapy. 
Maintenance therapy is excluded by rule from coverage. The elements of the coverage criteria are not satisfied. 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CMT; spinal, 1-2 regions (CPT code 98940).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is stable with no medical complexity. The complexity of the enrollee's 
nursing, medical, and rehabilitation needs do not require an inpatient rehab stay.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.