Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes are 
included in the dialysis rate. 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. The claim was not billed with a modifier to indicate the services were not related to ESRD. 
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 provided on May 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Protext (Q4246) provided on January 11, 2022. 
 
You asked the Plan to pay for the Protext. You say that you would like this code processed, as there is no 
discrepancy from your end, and you billed as per the benefits provided by the Plan. You also say that this is a 
major concern because you were told that code Q4246 was valid and billable. The Plan denied your request. 
The Plan says the clinical value and effectiveness of Protext in the setting of osteoarthritis have not been 
demonstrated in the peer-reviewed literature. 
 
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 pay for the Protext. Our physician reviewer found 
the documentation does not support that Protext (Q4246) is medically reasonable and necessary for the 
enrollee. Our reviewer also found that the documentation does not support that Protext (Q4246) is safe and 
effective for the enrollee. 
 
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 Protext have not been met. Therefore, we decided that the Plan does not 
have to pay for the Protext (Q4246) provided on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (L3-L4 Level) (22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (L4-L5 Level) (22870). 
 
You asked the Plan to pre-approve the Vertiflex Superion interspinous spacer device. You say that you highly 
recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative 
to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says the Vertiflex 
Superion interspinous spacer device is considered experimental and investigational as there is a lack of 
evidence to support interspinous spacer devices as safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion interspinous spacer device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(L3-L4 Level) (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; second level (L4-
L5 Level) (22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on October 25, 2021. 
 You asked the Plan to pay for procedure code 99223. You say that the enrollee needed the services as they 
were unable to walk nor stand. The Plan denied your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Review of claims history shows the exact same service (99223) was 
already billed for this enrollee and date of service by the same provider. 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 99223 
have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) 
provided on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percussion Massage Gun. 
 
You asked the Plan to pre-approve a Percussion Massage Gun. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 Percussion Massage Gun.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examinations, 
for prostate needle biopsy (G0416) diagnostic transrectal ultrasound (76872) prostate biopsy (55700) provided 
on September 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that it was medically necessary for the 
hospital to provide this service to the enrollee for the condition noted as to not hinder the enrollee's care, 
treatment and recovery of this illness. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 surgical pathology, gross and microscopic 
examinations, for prostate needle biopsy (G0416) diagnostic transrectal ultrasound (76872) prostate biopsy 
(55700) provided on September 7, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided on December 24, 2020, 
to January 22, 2021, at the Patient-Driven Payment Model (PDPM) rate originally billed. 
 
You asked the Plan to pay for SNF care at the original PDPM rate billed. You say that these services were 
necessary and are supported at the rate billed. The Plan denied your request. The Plan says that the SNF rate 
billed for these services is not supported, as the medical records do not include sufficient documentation to 
support the 21 skilled nursing visits billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate PDPM code. 
 
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 SNF care at the original PDPM rate billed. 
Our reviewer says that the skilled nursing visits are supported in the medical records. Our physician reviewer 
found additional medical records provided show that the enrollee had multiple medical problems that included 
diabetes, hypertension, heart failure, vascular dementia, and an open leg wound. The enrollee's open wound 
had colored exudate for which he was receiving antibiotic therapy. Wound care included appropriate active 
treatment, dressing changes, prescription medication, and wound assessment. The medical records provided 
support the 21 billed nursing visits, and that all 21 visits included skilled nursing 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 SNF care at the original PDPM rate billed have been met. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided on December 24, 2020, to 
January 22, 2021, at the Patient-Driven Payment Model (PDPM) rate originally billed.  
 
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 a periodic oral evaluation, bitewing x-rays, and cleaning 
(D0120, D0274, D1110) 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a periodic oral evaluation, bitewing x-rays, and cleaning (D0120, D0274, D1110)
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on June 27, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
based on the medical necessity of the service provided, you see no reason why the Plan would deny this claim. 
The Plan denied your request. The Plan says this request is not medically necessary because the enrollee does 
not meet the criteria requirements outlined in Medicare rules for this service. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the emergency 
department to the enrollees residence was not medically necessary. Our physician reviewer found the enrollee 
was not bedbound, as evidenced by their ability to walk. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Our reviewer 
found that transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollees condition. Our physician reviewer also found that a prudent layperson 
would not believe that immediate medical attention was required for someone who was being discharged from 
the hospital. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service September 
26, 2022. 
 You asked the Plan to pay for procedure code 77002. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 77002 is bundled into payment for 
code 76942. 
 
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 77002 
is a column II code to column I code 76942. 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 77002 billed for date of service September 26, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 19, 2022, to 
August 21, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that acute hospital inpatient services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from August 19, 2022, to August 21, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 18, 2022, 
to July 19, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like the claim to be 
reimbursed immediately, exactly as it was billed. The Plan denied your request. The Plan says the clinical 
information provided does not substantiate the need for an acute inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from July 18, 2022, to July 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 18, 2021. 
 
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. 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 the lab services provided on October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 25, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Uplizna. 
 
You asked the Plan to pre-approve Uplizna. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Uplizna. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Uplizna have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Uplizna.
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 you are requesting reconsideration stating the 
enrollee meets the criteria for acute inpatient rehabilitation and will benefit from acute inpatient rehabilitation 
that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the records 
show that it is not reasonable to expect that the enrollee will be able to safely participate in, or fully benefit 
from, the intensity of services of an IRF. It is not reasonable to expect the enrollee would be able to take part in 
3 hours of therapy 5 days a week or 15 hours of therapy a week. The enrollee is weak after hip surgery and 
have been limited by this weakness and fatigue. However, the rehabilitation needs are not complex and do not 
need a rehabilitation doctor 3 times a week. The enrollee may safely receive the services in other settings, for 
example, the skilled nursing facility where the enrollee was admitted last week, or home with home health 
services or home with outpatient therapy. 
 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care may safely be provided in a different 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.