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

 
We decided that the Plan has to pay for a third level of injection (procedure code 64495) provided to the 
enrollee on July 27, 2021, and July 28, 2021. 
 
You asked the Plan to pay for the third level. You say that this should be paid for. The Plan denied your 
request. The Plan says that the provider did not send in evidence of a unique circumstance to necessitate extra 
levels. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the third level. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee lives in Kenai, Alaska. The enrollee is receiving these injections in Anchorage, Alaska, 
which is 160 miles away from Kenai. It is not reasonable to ask the patient to transit that far for a separate 
session for the third level. 
 
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 third level have been met. Therefore, we decided that the Plan has to pay for 
a third level of injection (procedure code 64495) provided to the enrollee on July 27, 2021, and July 28, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for X-ray exams of the feet (73630) billed for date of service 
August 22, 2022. 
 
You asked the Plan to pay for X-ray exams of the feet. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 15, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the 
same date. Based on this information, we decided that the Medicare rules for X-ray exams of the feet have not been met. Therefore, we decided that the Plan does not have to pay for X-ray exams of the feet (73630) billed 
for date of service August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extended respiratory pathogen panel coded as 87633, 
87486, 87581 U0004 and U0005 provided January 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please se your supporting documentation to 
further process this claim The Plan denied your request. The Plan says the request does not meet Medicare 
rules as the panel performed had more than 5 pathogens on it. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the extended respiratory pathogen panel coded as 87633, 87486, 87581 U0004 and 
U0005 provided January 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says another MRI is not needed at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the enrollee saw 
their physician on 1/17/23, and there was concern of possible cauda equina syndrome. MRI of the lumbar spine 
was ordered urgently and done on 1/18/23. It showed degenerative changes and no severe stenosis. A note by 
the ordering physician acknowledged receipt of the report, and a plan to see the patient on 1/30/22. There is no 
indication in the record to explain the need for a repeat MRI of the lumbar spine. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa 1 mg capsules. 
 
You asked the Plan to pre-approve Vascepa. You say that Vascepa is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for payment under the Part B medical benefit. 
 
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 Vascepa 1 mg capsules.  
 
Benefits for Vascepa 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain fused to predominantly base metal 
(D2751) for tooth #9. 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says your photographs do not show the tooth has decay or loss due to fracture involving 
more than 50% of the biting edge of the tooth. This is a clinical requirement for a crown benefit. There is no 
clinical evidence to support medical necessity. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
 
 
 
 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 crown. Our reviewer says that the 
crown requested for tooth #9 is not medically necessary. Our physician reviewer found there is no submitted 
x-ray of the tooth to assess for decay or damage. A photo was included but it shows only some incisal wear and 
no other substantial damage.  The Plan requires that there be substantial damage to the tooth with 50% or more 
damage to the incisal edge to allow for a crown. As there is no substantial loss of tooth structure, it would be 
reasonable to restore any defect with a direct restoration and not a full crown. X-rays would be required for a 
proper assessment of the tooth as photos cannot show internal damage to a tooth.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown-porcelain fused to predominantly base metal (D2751) for tooth #9.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services billed with codes 95938, 95939, and 
95870 for 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 diagnosis code is invalid. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 testing services 
billed with codes 95938, 95939, and 95870 for April 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) in-home visits (97110, 97116, 
97530, 97140) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT in-home visits. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) in-home visits (97110, 97116, 97530, 97140) to be provided by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on August 11, 2022. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. You say that you became ill 
with nausea and bowel issues at a local restaurant and a bystander called for ambulance services. You say that 
since you did not call for the ambulance, you should not be held liable for cost. The Plan denied your request. 
The Plan says the ambulance benefit is a transportation benefit and without a transport there is no payable 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 11, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport provided on August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methocarbamol. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs 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 methocarbamol.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99214 for September 13, 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that follow-up visits are included in the global surgical 
package. 
 
We looked at the file and Medicare rules. Procedure code 99214 was related to and billed within 90 days of 
major surgical procedure 33208 billed for June 15, 2022. Payment for code 99214 is included in the global 
surgical package. Therefore, we decided that the Plan does not have to pay for the office visit billed with code 
99214 for September 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the enrollee has chronic right 
knee pain from osteoarthritis. He has had Left partial knee arthroplasty. He uses Voltaren gel for pain. He has 
tried intra-articular steroid injection without sustained benefit as well as Physical therapy. The request is for 
viscosupplementation with Euflexxa. Randomized trials do not support the efficacy of this approach. 
Therefore, the request is deemed not medically reasonable and 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 6, 2022, to 
March 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 6, 2022, to 
March 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
January 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 January 7, 2022, to 
January 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
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 procedure code 76700 billed for date of service October 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for a laparoscopic robotic 
right colectomy to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that you disagree with the denial. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and services.  
Services are available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
inpatient hospital services for a laparoscopic robotic right colectomy to be provided by an out-of-network 
(OON) provider.