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

 
We decided that the Plan does not have to pay for the home health services provided from February 10, 2022, 
to February 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. 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 February 10, 2022, to 
February 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 11, 2022, to 
July 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. 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 June 11, 2022, to July 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided on June 24, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that this service should be covered. The Plan denied 
your request. The Plan says this service is not covered when provided OON without prior authorization. 
 
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 drug testing (G0482) provided on June 24, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of carpometacarpal dislocation, other than 
thumb, with manipulation, each joint; requiring anesthesia provided to the enrollee on December 31, 2021. 
 
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 procedure is inconsistent with the modifier used. 
 
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 26675 is "Closed treatment of carpometacarpal 
dislocation, other than thumb, with manipulation, each joint; requiring anesthesia." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure was reported with 
Modifier 54 for Surgical Care Only, and F5 Right hand thumb for service provided. Modifier 54 cannot be 
verified. The procedure report describes one physician performed treatment. Modifier 54 would be appended 
when a physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding this modifier to 
the usual procedure code. The modifier for right hand thumb is inappropriate to append to a procedure code for 
treatment of dislocation other than thumb. In this case, this modifier cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each 
joint; requiring anesthesia provided to the enrollee on December 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 hours of psychological or neuropsychological test 
administration and scoring. 
 
You asked the Plan to pre-approve psychological or neuropsychological test administration and scoring. You 
say that psychological or neuropsychological test administration and scoring is medically necessary. The Plan 
denied your request. The Plan says 8.5 hours of psychological or neuropsychological test administration and 
scoring is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 8.5 hours of psychological or neuropsychological test administration and scoring. Our reviewer says that the requested psychological or 
neuropsychological test administration and scoring are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this testing is intended to diagnose and characterize the neurocognitive 
effects of medical disorders that impinge directly on or indirectly on the brain including detection of neurologic 
disease based on quantitative assessment of neurocognitive abilities, differential diagnosis between 
psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central nervous system 
disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders or 
assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies 
among individuals with neuropsychiatric disorders, this enrollee does not meet the criteria for an additional 
units as the enrollee is not showing severity of symptoms that would warrant the additional units as being 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8.5 hours of psychological or neuropsychological test administration and 
scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve 8.5 hours of 
psychological or neuropsychological test administration and scoring.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve a Synvisc injection. You say that a Synvisc injection is medically necessary. 
The Plan denied your request. The Plan says the requested Synvisc Injection does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Synvisc injection. Our reviewer says 
that a Synvisc injection is not medically necessary in this case. Our physician reviewer found that in this case, 
the record indicates that the enrollee has a diagnosis of osteoarthritis of the shoulder. 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 provided record does not indicate the criteria of the Medicare LCD are satisfied. 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 a Synvisc injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Synvisc injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an orthopedic visit. You say that you do not want to see this in-network 
provider because you do not trust them. The Plan denied your request. The Plan says no preauthorization by a 
primary care provider was provided, and there are other providers who can perform this service within 
network. 
 
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 orthopedic visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the device makes it easier for you to 
check your blood sugar. The Plan denied your request. The Plan says you do not meet the criteria. 
 
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 does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility admission and 
services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical records warrant inpatient 
rehabilitation. The Plan denied your request. The Plan says IRF services you are requesting for the enrollee do 
not meet the requirements for approval. The enrollee has participated in therapies and requires moderate 
assistance for bed mobility, the request is not medically necessary, and the enrollee may safely receive services 
at an alternate 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
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 admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided to the enrollee on June 27, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not 
used in clinical management, exceeds the needs of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has chronic pain on opioids who underwent urine drug testing and definitive drug 
testing was performed. However, the records do not show that the patient's urine drug screening was abnormal 
or unexpected to justify confirmation testing, particularly for many drug classes that are not applicable or 
pertinent to this patient's case. Therefore, the records do not support that it was reasonable testing for 22+ drug 
classes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (G0483) provided to the 
enrollee on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and bag hooks 
(K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve a power seat elevation system and bag hooks. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items 
are not a covered benefit.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Bag hooks do 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. A power seat elevation system is 
statutorily non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does 
not have to pre-approve a power seat elevation system (E2300) and bag hooks (K0108) for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97116 and 97530) provided on July 
19, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services should be resubmitted with the KX modifier in order to be 
processed for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the KX modifier should 
be used as a confirmation that services are medically necessary after the beneficiary has exceeded the KX 
modifier threshold of incurred expenses. If a claim is submitted without KX modifiers and the cap is exceeded, 
those services will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the record shows that the enrollee in question has 
exceeded the KX modifier threshold of incurred expenses, but the KX modifier was not used on the 
claims/services at issue. Therefore, we decided that the Plan does not have to pay for therapy services (97110, 
97116 and 97530) provided on July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant control (E2311) alert or alarm device, Braze 
Sentina Plus Kit 5 (A9280) controller mount option, Qlogic (Quantum) (K0108) XLR USB Adapter 2-port 
(K0108) and transfer handles (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee must have the ability 
to move independently and perform independent weight shifts throughout the day. the only way to do that is 
with the use of the power wheelchair and all power seat functions and accessories that have been 
recommended. The Plan denied your request. The Plan says the alert or alarm device is a non-covered item 
under Medicare. The controller mount option - QLogic, XLR USB Adapter 2-port, and transfer handles do not 
meet general DME criteria, and the enrollee demonstrated safe use of power wheelchair and operation skill and 
therefore the attendant control is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve attendant control (E2311) alert or alarm device, Braze Sentina Plus Kit 5 (A9280) controller 
mount option, Qlogic (Quantum) (K0108) XLR USB Adapter 2-port (K0108) and transfer handles (K0108).
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 
18, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. 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 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection (E2311), expandable controller 
(E2377) and harness (E2313). 
 
You asked the Plan to pre-approve electronic connection, expandable controller, and harness. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee requires a Hoyer lift for all 
transfers. The enrollee is not expected to operate the wheelchair independently, since an attendant control has 
been requested. Member's caregivers operate member's Hoyer lift for transfers, so caregivers have upper limb 
strength and function are adequate to control the power options using their own switches which are included in 
the allowance of these power options. Based on this information, we decided that Medicare rules for coverage 
of electronic connection, expandable controller, and harness have not been met. Therefore, we decided that the 
Plan does not have to pre-approve electronic connection (E2311), expandable controller (E2377) and harness 
(E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 9, 2021, to November 19, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the clinical documentation does not support that the following diagnosis impacted this hospital admission A41.89, other specified sepsis and R65.20, severe 
sepsis without septic shock. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the 
records did not support DRG 871 in this case. The records did not support the use of diagnosis code A41.89 - 
other specified sepsis - in this case. The records did not support the use of diagnosis code R65.20 - severe 
sepsis without septic shock - in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 9, 2021, to November 19, 2021.