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

 
We decided that the Plan has to pre-approve home health physical therapy (PT), home health occupational 
therapy (OT), home health aide, and home health social services. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are necessary for 
the enrollee. The Plan denied your request. The Plan says that the requested home health services are not 
medically necessary. The Plan also says that the requested care is custodial in nature. 
 
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 requested home health services are medically necessary. Our physician reviewer found the 
provided documentation indicates the enrollee has functional impairments and worsening clinical status. The 
reviewer found that the enrollee is home bound, requires PT and OT evaluation and requires aid to assist with 
safe activities of daily living (ADLs). The reviewer also found that the enrollee requires social service support 
to assist with ongoing services since they have neurodegenerative disease. Therefore, the reviewer found that 
the requested home health services are 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 been met. Therefore, we decided that the Plan has to 
pre-approve home health physical therapy (PT), home health occupational therapy (OT), home health aide, and 
home health social services.  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease polymerase chain reaction (PCR) panel 
(87801, 87798, 87481) collected on March 15, 2022. 
 
You asked the Plan to pay for the infectious disease PCR panel. You say that these services are payable by 
Medicare and were denied as experimental in error. The Plan denied your request. The Plan says PCR testing is 
not indicated as the following are appropriate means to verify fungal infection: direct microscopic examination 
with potassium hydroxide, fungal culture of desquamated subungual material, or fungal stain of a nail clippings 
fixed in formalin. 
 
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 the infectious disease PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in this particular case, the standard of care to evaluate onychomycosis 
and onychodystrophy is currently a KOH and fungal culture of the toenail specimen. These tests have been 
proven to be efficacious and inexpensive.  It appears that the PCR testing has exceeded the enrollees needs, 
and is certainly not standard of care at this point for onychodystrophy testing. Therefore, the PCR testing of 
this enrollees toenails 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 infectious disease PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the infectious disease polymerase chain reaction (PCR) panel (87801, 87798, 
87481) collected on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve introduction/injection of anesthetic agent (nerve block), 
diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches (CPT 64495), third level. 
 
You asked the Plan to pre-approve introduction/injection of anesthetic agent (nerve block), diagnostic or 
therapeutic procedures on the paravertebral spinal nerves and branches, third level. You say that 
introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the 
paravertebral spinal nerves and branches, third level is medically necessary. The Plan denied your request. The 
Plan says introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the 
paravertebral spinal nerves and branches, third level does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 introduction/injection of anesthetic 
agent (nerve block), diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches, third 
level. Our reviewer says that introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic 
procedures on the paravertebral spinal nerves and branches third level is not medically necessary. Our 
physician reviewer found the third levels exceeds utilization criteria of the LCD. Therefore, the request for a 
third level 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 introduction/injection of anesthetic agent (nerve block), diagnostic or 
therapeutic procedures on the paravertebral spinal nerves and branches, third level. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve introduction/injection of anesthetic agent 
(nerve block), diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches  
(CPT 64495), third level.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 1, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that transport to the hospital was not necessary. 
The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment 
with no transport (A0998) provided on August 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69420 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 69420. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 69420 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 69420 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 69420 billed for date of service July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Viero diabetic testing supplies. 
 
You asked the Plan to pre-approve diabetic testing supplies. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the requested OneTouch brand supplies are not the Plan's 
preferred brand of diabetic testing supplies, and the enrollee can used preferred-brand supplies such as 
Freestyle or Contour. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit coverage to certain brands.  
 
We looked at the file and Medicare rules. The requested OneTouch brand supplies are not among the Plans 
preferred brands. The Plan is offering the needed diabetic test supplies from a preferred brand such as Freestyle 
or Contour. Based on this information, we decided that Medicare rules for coverage of diabetic testing supplies 
have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Viero diabetic 
testing supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state provided on September 13, 
2022. 
 
  You asked the Plan to pay for a determination of refractive state. You say that you called the Plan to find out if 
you could have the refraction done with your medical appointment. You also say that you were told that you 
could. The Plan denied your request. The Plan says eye refractions are only covered by the Plan if performed 
by a participating provider and performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed during a routine examination by a Plan routine vision 
care provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions during a routine examination 
are covered when performed by a Plan routine vision care provider. The record shows this was not a routine 
vision examination, but a medical examination. Based on this information, we decided that the Plan's rules for 
coverage of a determination of refractive state have not been met. Therefore, we decided that the Plan does not 
have to pay for a determination of refractive state provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a shoe that is an integral 
part of a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides 
coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics (L3020).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapies provided on August 18, 
2022, to August 22, 2022. 
 
You asked the Plan to waive the copayment for physical therapies. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $30 
copayment for outpatient rehabilitation services. There were 3 visits, resulting a total copayment amount of 
$90. 
 
You have been asked to pay $30 copayment for each physical therapy. This item/service falls within the 
outpatient rehabilitation services 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 
physical therapies provided on August 18, 2022, to August 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the documentation does not indicate failure, intolerance, or 
contraindication to an anticholinergic medication (examples: oxybutynin, tolterodine, trospium, solifenacin, 
darifenacin). 
 
The Plan follows Medicare rules. Medicare rules say that onabotulinumtoxina is indicated for the treatment of 
overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults and 
patients five years of age and older who have an inadequate response to or are intolerant of an anticholinergic 
medication. 
 
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 Botox. Our reviewer says that the 
requested drug, Botox, is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee has had an inadequate response to or is intolerant to an anticholinergic 
medication. Mirabegron is a beta-3 adrenergic agonist not an anti-cholinergic. Therefore, the reviewer found 
that the request for Botox 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve onabotulinumtoxina (Botox) (J0585).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63012 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 63012. You say that the procedure should not be included in 
what was billed. The Plan denied your request. The Plan says no separate payment is made. 
 
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 63012 is a column II code to column I code 22633. Code 63012 has 
not been billed with an appropriate modifier to bypass the edit. We find that procedure code 20936 has a status 
indicator of B on the Physician Fee Schedule. This means that code 20936 is not separately payable. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 63012 billed for date of service May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11011, 13132, 13152, 14040, and 14061 
billed for date of service March 23, 2021. 
 
You asked the Plan to pay for the billed services. You say that the necessity of the services is clear. The Plan 
denied your request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 13152 is a column II code to column I code 14061. Code 13152 has 
not been billed with an appropriate modifier to bypass the edit. We have also confirmed that code 11011 is a 
column II code to column I code 13152. Code 11011 has not been billed with an appropriate modifier to bypass 
the edit. Based on the claim submitted, the Medicare billing criteria have not been met. 
 
In this case, you billed assistant surgery services, using modifier AS, for Current Procedural Terminology 
(CPT) codes 11011, 13132, 13152, 14040, and 14061. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon 
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 11011, 13132, 13152, 14040, and 14061 billed for date of service March 23, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing provided on February 8, 2022. 
 
You asked the Plan to pay for diagnostic testing. The Plan denied your request. The Plan says that the Plan 
pays for these services when the facility where the services were provided bills the Plan. 
 
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 Plan has not provided us with a rule to support their denial. 
Therefore, we decided that the Plan has to pay for diagnostic testing provided on February 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
October 28, 2021, to May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on October 28, 2021, to May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 
billed for date of service February 2, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381. You say that these 
services are supported in the medical record. The Plan denied your request. The Plan says this code is included 
in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88377 and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88377 and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377 and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 billed for date 
of service February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator leads provided on June 23, 2022. 
 
You asked the Plan to pay for the electrical stimulator leads. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says there is no evidence to support the ordering provider is treating the 
patient. 
 
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. The documentation does not include evidence to support that the ordering provider is treating the 
enrollee. 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 leads provided on 
June 23, 2022.