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

 
We decided that the Plan does not have to pay for the lab testing services provided on June 10, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the codes 
remain not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 The file shows that urinary tract infection panel testing was provided. The medical records provided do not 
show that the service billed with the -59 modifier is a distinct procedural service. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. Based on this 
information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on June 10, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Durolane injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered investigational and not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the record 
indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The record provided is insufficient to 
establish that the enrollee has failed conservative nonpharmacologic therapy or simple analgesics, such as 
acetaminophen. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Durolane injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on February 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 00860 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 00860 is anesthesia for extraperitoneal procedures in 
lower abdomen, including urinary tract; not otherwise specified. 
 
We find that CPT code 00860 is not supported in the medical record. Specifically, the documentation does not 
support the billing of 88 units of this code. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services rendered on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need more rides. The Plan 
denied your request. The Plan says you have used 99 trips, and have 1 trip remaining in 2022. The Plan also 
says that transportation benefits beyond the 100 allotted one-way trips are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that a consult to this provider is recommended by 
both your neurologist and your primary care physician (PCP). You also say that you have submitted supporting 
documents. The Plan denied your request. The Plan says per the EOC and the Summary of Benefits and 
Coverage, out of network providers are only covered under limited circumstances, such as with a prior 
authorization or when urgent or emergent. The Plan also says that this situation is neither, nor may the member 
receive an in network consult at a participating provider in their area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 1, 
2022, to January 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary and reasonable for the enrollee's condition. The Plan denied your request. The Plan says an inpatient 
hospital admission was not medically necessary in this case as the enrollee did not require the level of care 
provided in an inpatient setting. 
 
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 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 that the enrollee was brought back to the hospital for a fall following discharge for 
alcohol withdrawal treatment. The medical records documented acute kidney injury and dehydration, and 
treatment included fluids, pain medication, insulin, vitamins, anti-hypertensives, and physical therapy. The 
admission to the hospital started on January 1, 2022, and continued to January 10, 2022, while the enrollee 
awaited transfer to a sub-acute rehab facility. During those days the enrollee was hemodynamically stable and 
could have been treated at a lower level of care. It was not expected that on the date of admission the enrollee 
would require 2 midnights or more of ongoing acute care services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 January 1, 2022, to January 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular disease screening provided on July 2, 
2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular disease screening provided on July 2, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional speech therapy (ST) sessions. 
 
You asked the Plan to pre-approve 10 additional ST sessions. You say that speech therapy is medically 
necessary for clinical dysphagia treatment. The Plan denied your request. The Plan says that based on the 
clinical documentation the enrollee is able to safely swallow a soft diet, and services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional ST sessions. Our reviewer 
says that 10 additional speech therapy sessions are medically necessary. Our physician reviewer found that the 
enrollee continues to be on modified textures which is having a significant clinical effect. The enrollee would 
continue to require the assessment and treatment of a skilled speech therapist due to aspiration precautions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional ST sessions have been met. Therefore, we decided that the Plan has 
to pre-approve 10 additional speech therapy (ST) sessions.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an ESI. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using same scale for at least three months. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ESI. Our reviewer says that the 
requested ESI is not medically reasonable and necessary. Our physician reviewer found that the duration of 
50% pain relief is not documented as exceeding 3 months. Therefore, the request does not meet the LCD 
criteria and is deemed 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 an ESI have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you need to monitor your blood sugars. The 
Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an OON provider. 
 
You asked the Plan to pre-approve diabetic shoes. You say that there is only one provider supplier in-network. 
The Plan denied your request. The Plan says the authorization was denied because the request was for an out-
of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diabetic shoes to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 70460. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70460 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 70460 
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 70460 billed for date of service March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve healthy meals. 
 
You asked the Plan to pre-approve healthy meals. You say that the enrollee has a chronic condition of 
hypertension that requires intensive care coordination. You say that the enrollee is an appropriate candidate for 
the Healthy Groceries Benefit. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of healthy meals have not been met. Specifically, we have confirmed that you do not have one of the 
eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve healthy meals.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 1, 2020, to March 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Minimum Data Set (MDS) assessment does not fall within the first eight days of the skilled 
stay that started on December 23, 2019. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The file shows that the stay originally began on December 23, 2019. The MDS assessment would then have to 
be submitted somewhere between December 23, 2019 and December 30, 2019. The MDS was submitted 
outside of this 8 day range on December 18, 2019. 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 
skilled nursing facility (SNF) services provided to the enrollee from March 1, 2020, to March 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on December 30, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the bill should have been sent with the 
physician's name instead of the facility. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. 
 
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 outpatient visit provided on December 30, 
2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 28, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 8, 2020. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary for tracking. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 in this case 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 lab services provided on September 8, 2020.