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

 
We decided that the Plan does not have to pre-approve 2 home health occupational therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the services are not medically necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee requires 
supervision for safety and some assistance for housekeeping and meal preparation. However, this assistance 
does not require the services of a skilled occupational therapist and can be provided as personal care assistance 
if needed. Therefore, the continued home health occupational therapy 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 home health occupational therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-disease testing (0241U) provided on December 
20, 2022. 
 
You asked the Plan to pay for infectious-disease testing. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of infectious-disease 
testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious-disease 
testing (0241U) provided on December 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Bupivacaine (J3490) provided on December 8, 2022. 
 
You asked the Plan to pay for the Bupivacaine. You say that this drug has been used as a medically necessary 
part of the enrollee's treatment. You also say that separate expenses are incurred for this medication. The Plan 
denied your request. The Plan says the surgical procedure is included in the 000-day global period. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. 
 
 We looked at the file and Medicare rules. The record shows that the enrollee had the epidural steroid injections 
(codes 64483 and 64484) performed on December 8, 2022. The MFSDB shows that the postoperative period 
for this code is the day of surgery/procedure. The enrollee received the Bupivacaine (J3490) on December 8, 
2022, which is the same day the initial procedure was rendered. Therefore, this procedure is bundled as part of 
the global surgical fee because it was reported the same day as the epidural steroid injections (codes 64483 and 
64484). Therefore, we decided that the Plan does not have to pay for the Bupivacaine (J3490) provided on 
December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit and treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve office visit and treatment to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
office visit and treatment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on December 2, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not covered as billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the signature date if missing on the medical necessity page. This 
means the validity of the items rendered cannot be verified. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulator supplies provided on December 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (code 43239). 
 
You asked the Plan to pre-approve an esophagogastroduodenoscopy. You say that an 
esophagogastroduodenoscopy is medically necessary. The Plan denied your request. The Plan says the 
requested esophagogastroduodenoscopy does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that endoscopic procedures are covered when reasonable 
and necessary for the individual patient. 
 
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 esophagogastroduodenoscopy. Our 
reviewer says that the requested esophagogastroduodenoscopy is not medically necessary in this case. Our 
physician reviewer found that contemporary guidance supports a 5-year endoscopic surveillance for short 
segment nondysplastic Barrett's. In the absence of presenting or intervening symptoms, the 3-year surveillance 
interval requested for this enrollee is too soon and not medically necessary nor appropriate at this time.  
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 esophagogastroduodenoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an esophagogastroduodenoscopy (code 43239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service December 16, 2022. 
 
You asked the Plan to pay for code 99223. You say that this claim should be paid as this charge is not bundled 
with anything else. The Plan denied your request. The Plan says you billed the wrong code for this place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, a 
comprehensive exam; and medical decision making of high complexity. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically the records show that the 
patient was in observation care on the date of service in question.  The code you billed (99223) is used to report inpatient care services.  Observation is not considered an inpatient status, and there are other CPT codes used to 
specify evaluation and management services performed during an observation stay (i.e., codes 99218-99220). 
Based on this information, we decided that Medicare rules for coverage of code 99223 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99223 billed for date of service December 
16, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee can receive further services at a lower level of care. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme infusion (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the enrollee has had two Feraheme infusions in the 
past. The Plan denied your request. The Plan says the requested infusion 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 Feraheme. Our reviewer says that the 
requested drug, Feraheme, is not medically necessary. Our physician reviewer found Feraheme is indicated for 
treatment of iron deficiency anemia with chronic kidney disease and iron deficiency anemia with intolerance or 
unsatisfactory response to oral iron. The reviewer found that the provided medical records do not document the 
enrollee in this case has chronic kidney disease or iron deficiency anemia with intolerance or unsatisfactory 
response to oral iron. Therefore, the reviewer found that the the requested drug 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme infusion (Q0138).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99222) provided on October 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code was 
reported within 3 days of a prior initial hospital inpatient or observation care service 99222 for the same 
diagnosis and by a provider with the same specialty. 
 
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 rules also say that in the inpatient hospital setting all physicians (and qualified nonphysician 
practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 
- 99223). 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that code 99222 was reported within 3 days of a prior initial 
hospital inpatient or observation care service 99222 for the same diagnosis and by a provider with the same 
specialty. However, per Medicare rules, all physicians (and qualified nonphysician practitioners where 
permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 - 99223). As such, 
code 99222 is supported and payable in this case. Therefore, we decided that the Plan has to pay for the 
services (99222) provided on October 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an out-of-area retina specialist. 
 
You asked the Plan to pre-approve consultation. You say that this is an emergency. You say that you are out of 
state. You say that you burned your retina with an infrared telescope. You also say that you have been referred 
to a retina specialist. The Plan denied your request. The Plan says there is no indication that you cannot wait to 
see a network provider once you return home. 
 
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 consultation. Our reviewer says that an 
out-of-area consultation with a retina specialist is not medically necessary. Our physician reviewer found the 
provided documentation indicates drusen in the macula. The reviewer found that this condition is chronic and 
does not develop acutely. The reviewer found that documentation indicates you do not have acute vision loss. 
The reviewer found that the ophthalmology examination and retinal imaging do not indicate an urgent medical 
condition that requires immediate evaluation with a retinal specialist. therefore, the reviewer found that the 
requested out-of-area consultation is 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 consultation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit with an out-of-area retina specialist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J7620 billed for date of service October 21, 
2022. 
 
You asked the Plan to pay for procedure code J7620. You say that the services at issue have been billed 
correctly. 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 J7620 when provided in a facility setting is 0. The MAI value for this code 
is 3. You billed 1 unit of this code, 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 J7620 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code J7620 billed for date of service 
October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this lab service is medically necessary and 
coverable. 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 March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 12, 2022. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you need to bill the patient's primary insurer. 
 
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 contacted 
you multiple times via phone and fax advising you that you needed to bill the patient's primary insurer.  In 
addition, the Plan has identified the primary insurer for you to bill.. As the secondary insurer, the Plan cannot 
be held responsible for the medical services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for medical services provided on September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-terrain rollator walker. 
 
You asked the Plan to pre-approve the requested walker. You say that your regular walker does not work for 
you to get around. The Plan denied your request. The Plan says the device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker. Your current walker serves the same purpose as the requested walker. 
Therefore, we decided that the Plan does not have to pre-approve an all-terrain rollator walker.
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 August 26, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. 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 August 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the ExoDX Prostate Test (0005U) provided September 19, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that effective for claims for dates of service on or 
after December 1, 2019, EPI is covered by Medicare Administrative Contractor with jurisdiction over your 
Waltham, Massachusetts laboratory, National Government Services, Inc under LCD L37733. The Plan denied 
your request. The Plan says that non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory testing by a contract provider. The file does not show that the plan 
provided notice that the laboratory testing would not be covered. Under Medicare rules, this means the 
laboratory testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
ExoDX Prostate Test (0005U) provided September 19, 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.