Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve wheelchair ramp. You say that the enrollee needs a ramp to be able to travel 
in and out of the home. The Plan denied your request. The Plan says this equipment is presumptively non-
medical in nature. 
 
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 a wheelchair ramp.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73700 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 73700. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 73700 is bundled into 
payment for code 78815. 
 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 73700 
is a column II code to column I code 78815. 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 73700 billed for date of service July 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (physical therapy and home health 
aide). 
 
You asked the Plan to pre-approve the home health services. You say that you need to see the neurologist so 
they can tell you if you need physical therapy. You also say you cannot get ahold of your primary care 
physician's office on the phone to get an appointment, and they are not sending the referrals. The Plan denied 
your request. The Plan says you must get approval in advance from your PCP. The Plan also says that orders 
for physical therapy and home health aide were not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the patients plan of care must reflect the 
physician or allowed practitioner ordered services that the home health agency provides either directly or under 
arrangement.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve home health services (physical therapy and home health aide).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 billed for July 14, 2022. 
 
You asked the Plan to pay for code G0483. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. Based on this information, we decided 
that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the Plan does 
not have to pay for code G0483 billed for July 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 25, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you want the Plan to reconsider the denial for 
the services. The Plan denied your request. The Plan says Medicare claims must be filed no later than 12 
months (or 1 full calendar year) after the date when the services were provided. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until June 15, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for laboratory services provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Interfyl (Q4171). 
 
You asked the Plan to pre-approve Interfyl. You say that this product is not required to be licensed or approved 
by the Food and Drug Administration. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Interfyl have been met. Specifically, 
the file does not include documentation to support why the enrollee needs the requested service. Therefore, we 
decided that the Plan does not have to pre-approve Interfyl (Q4171).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for part B drugs and a myocardial perfusion 
imaging provided on July 26, 2022. 
 
You asked the Plan to waive the cost share for part B drugs and a myocardial perfusion imaging. You say that 
you aren't sure what your being charged for. 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 20% 
coinsurance for Medicare Part B drugs and a $100 copayment for diagnostic radiology services. 
 
 
 You have been asked to pay a total of $221.15 for part B drugs and a myocardial perfusion imaging. The drugs 
fall within the Medicare Part B prescription drugs benefit category and the imaging falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 
cost share for part B drugs and a myocardial perfusion imaging provided on July 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (codes 64493 and 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that the provider said your cartilage needs to 
be fused and that they would try the injections, but the provider did not mention anything about physical 
therapy. You also say that you had done shots in your knees which helped, and you would like to get these 
shots to see if they will help. The Plan denied your request. The Plan says you have not tried physical therapy, 
and there is no specific documentation of asymmetry of motor, sensory, or reflex function. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the criteria 
listed in the Medicare rules section of this letter. 
 
 
 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 facet joint injections. Our reviewer says 
that you do not meet the criteria for coverage for facet joint injections. Our physician reviewer found you have 
radiculopathy and in addition there is no documentation of failure to respond to non-invasive/conservative 
management (as tolerated). The review has determined that you do not have a condition which is indicated for 
coverage. Our reviewer also found that there are no limitations as listed in the LCD that would prevent 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (codes 64493 and 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that being in an IRF would allow for around the 
clock observation and treatment as well as very comprehensive therapy. You say that the therapy is well 
beyond what home health can provide and well beyond what your spouse can do to help. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and your needs can be met at a lower level 
of care. 
 
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 that you have no active comorbidities and do not require continued inpatient 
hospitalization during rehabilitation for close medical motoring. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement between the laboratory and the dialysis facility for payment. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 22, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services you received on June 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance claims may use the -GY modifier on 
line items for non-covered mileage, and liability for the service will be assigned correctly to the beneficiary. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with the -GY modifier, which 
indicates that the services in question are non-covered. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the ambulance services you received on June 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 20, 2021, 
to October 19, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
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 September 20, 2021, to 
October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi (Bevacizumab). 
 
You asked the Plan to pre-approve Bevacizumab. You say that it is medically necessary to treat the enrollee's 
metastatic adenocarcinoma with Bevacizumab. The Plan denied your request. The Plan says Mvasi 
(Bevacizumab) is not reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Bevacizumab. Our reviewer says that 
Bevacizumab is not reasonable and necessary for the enrollee. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of metastatic adenocarcinoma of unknown primary. The FDA has not 
stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested 
service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bevacizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Mvasi (Bevacizumab).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration 
or phacoemulsification); without endoscopic cyclophotocoagulation (66984) provided December 14, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that this claim was once processed and paid and 
then it was processed in negative payment for primary payer missing/incomplete/invalid prior insurance carrier. 
The Plan denied your request. The Plan says the claim must be billed to the primary carrier. 
 
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 another Plan 
listed as the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the 
surgical procedure until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis 
(1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); 
without endoscopic cyclophotocoagulation (66984) provided December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 23, 2022. 
 
You asked the Plan to pay for the lab services. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting.  Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 99214. The Plan denied your request. The Plan says payment for 
code 99214 is bundled into payment for code 20611. 
 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 99214 
is a column II code to column I code 20611. 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 99214 billed for date of service August 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 99255. You say that this service is supported as billed. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service June 1, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the procedure you had on March 31, 2022. 
 
You asked the Plan to pay for the procedure. You say that the provider's office told you the procedure was 
approved. The Plan denied your request. The Plan says that the procedure was billed with the incorrect code. 
 
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. 
 
You were provided the procedure by a contract provider. The file does not show that the Plan provided notice 
that the procedure would not be covered. Under Medicare rules, this means the procedure is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the procedure you had on March 31, 
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.