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

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on September 29, 2021. 
 
You asked the Plan to pay for the physical therapy services. 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 in-network benefits should be honored, and the claim processed for payment. The Plan 
denied your request. The Plan says the billed services are not supported. 
  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on September 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit (up 
to 2 hours) (99601), and home infusion/specialty drug administration, per visit (up to 2 hours); each additional 
hour (99602) provided on June 4, 2020. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure codes with a Status Code of "I", 
indicates that the code is not valid for Medicare purposes and are not payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to 
pay for the home infusion/specialty drug administration, per visit (up to 2 hours) (99601), and home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (99602) provided on June 
4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve face masks. 
 
You asked the Plan to pre-approve face masks. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says face masks are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that non-reusable disposable supplies are 
not covered 
 
While face masks may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. 
Therefore, we decided that the Plan does not have to pre-approve face masks.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dual-energy X-ray absorptiometry (DXA), bone density 
study (77085) provided on October 21, 2021. 
 You asked the Plan to pay for code 77085. 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 as billed. 
 
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 77085 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 code 
77085 have not been met. Therefore, we decided that the Plan does not have to pay for the Dual-energy X-ray 
absorptiometry (DXA), bone density study (77085) provided on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on November 
3, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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. 
 
We find that CPT code 70450 may be eligible for payment when billed with CPT code 70496. However, the 
claim information does not show that the code at issue was billed with a modifier suitable for payment. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the computed tomography (CT) scan provided on November 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 16, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you refused transport due to fear of a 
coronavirus exposure. You also say that you would like for this claim to be paid. The Plan denied your request. 
The Plan says since no transport was provided, 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 October 16, 2021. 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 the ambulance response and treatment, no 
transport, (A0998) provided on October 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 16, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because you were 
told that this provider is in-network. The Plan denied your request. The Plan says no authorization was received 
for this service. 
 
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 office visit (99214) provided on August 16, 
2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (64483). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that this injection is medically 
necessary for your pain. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for epidural steroid injections to be covered, the 
enrollee should be part of an active rehabilitation program, home exercise program or functional restoration 
program. 
 
We looked at the file and Medicare rules. In this case, there is no evidence you are part of an active 
rehabilitation program, home exercise program or functional restoration program. Based on this information, 
we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an epidural steroid injection (64483).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Infed and Venofer. 
 
 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 Injectafer. Our physician reviewer 
found that in this case, the record indicates that the enrollee has iron deficiency anemia. The requested 
medication is a new start. The Plan requires a trial of Infed and Venofer before they will approve the requested 
drug. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternatives. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternatives. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on 
November 4, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date. The 
Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists between 76705 and 93976.  
 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 claim. 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 ultrasound of the abdomen (76705) provided on November 4, 
2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve office visits for a sleep study (95800) and an oral appliance 
(E0486).  
 
You asked the Plan to pre-approve office visits for a sleep study and an oral appliance. You say that the 
services are not related to dental. The Plan denied your request. The Plan says that the facility and provider are 
not Medicare certified. 
 
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. The plan did not submit documentation supporting the facility is not a Medicare 
approved facility and the requested dentist is not on the opt out list. Therefore, we decided that the Plan has to 
pre-approve office visits for a sleep study (95800) and an oral appliance (E0486). 
 
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 Guardant360 testing provided on July 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim billed a place of service as an independent laboratory. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not indicate that the specimen was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 testing provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that the allowable amounts do not match your 
expectations. The Plan denied your request. The Plan says the services were previously paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. We find that CPT code 99310 was previously billed and paid for by the 
Plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the nursing facility care provided on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on November 18, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 70544 is magnetic resonance angiography, head; without 
contrast material(s). We find that CPT code 70544 may be eligible for payment when billed with CPT code 
70551. The claim provided does not show that the code at issue was billed with a modifier suitable for 
payment. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the imaging services provided on 
November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair (K0003) and sales tax (S9999), 
purchased on June 1, 2021. 
 
You asked the Plan to pay for the wheelchair and sales tax. You say that the items should be covered. The Plan 
denied your request. The Plan says you obtained these items through a provider that is not enrolled with 
Medicare. 
 
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 lightweight wheelchair (K0003) and 
sales tax (S9999), purchased on June 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the inpatient hospital services provided on June 7, 
2021. 
 
You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan 
says that the claim processed correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copay for inpatient hospital care.  
 
The Plan says you must pay a $2524 copay for the services at issue. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copay for the services provided. Therefore, we decided that the Plan has 
to waive the cost share for the inpatient hospital services provided on June 7, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that a nursing home facility would not meet 
your needs nor provide you with a quality of life. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage. 
 
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 your rehabilitation needs can be met at a lower intensity setting such as in a skilled 
nursing facility with therapies.  
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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 12, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cubii exercise machine (E1399), purchased on July 
30, 2021. 
 
You asked the Plan to pre-approve the Cubii exercise machine. You say that the item is medically necessary. 
The Plan denied your request. The Plan says your request is not a covered benefit because exercise equipment 
is not primarily medical in nature, is not primarily and customarily used to serve a medical purpose and is 
generally useful to a person in the absence of illness or injury. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Cubii exercise machine (E1399), purchased on July 30, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 20, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on January 20, 2021.