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

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (99204) provided January 
7, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says insufficient documentation was submitted to support 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 outpatient mental health services 
(99204) provided January 7, 2022. have been met. No itemized bill was provided to support reimbursement of 
these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services 
(99204) provided January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71260 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 71260. The Plan denied your request. The Plan says payment for 
code 71260 is bundled into payment for code 71275.  
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 71260 
is a column II code to column I code 71275. 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 71260 billed for date of service April 15, 2022.
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 your back will lock-up and not heal correctly without 
the proper help and rehabilitation. The Plan denied your request. The Plan says needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
laminectomy and spinal fusion. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do 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 can be provided in a different level of care. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 is considered bundled and not separately 
payable. 
 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eternal upper limb tremor stimulator of the 
peripheral nerves of the wrist (K0108). 
 
You asked the Plan to pre-approve the Cala Trio device. You say that the use of Cala Trio is enabling the 
enrollee to avoid any type of invasive and costly surgical procedures to treat hand essential tremor. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Cala trio device in the setting of 
essential tremor have not been demonstrated in the peer- reviewed literature. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the eternal upper limb tremor stimulator of the peripheral nerves of the wrist (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and OsteoCel allograft for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this request in the setting of spinal fusion surgery 
has not been demonstrated in the peer-reviewed literature. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate the 
safety and efficacy as there is insufficient evidence to recommend these cellular bone matrices over the cheaper 
alternative. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested OsteoCel allograft, in this case, is 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate and OsteoCel allograft for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 14, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, 
and 0033U.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77065) provided on December 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code was billed 
twice on the same date. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (77065) 
provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute grafts (Q4133-Grafix prime, grafixpl 
prime, stravix and stravixpl, per square centimeter). 
 
You asked the Plan to pre-approve skin substitute grafts (Q4133-Grafix prime, grafixpl prime, stravix and 
stravixpl, per square centimeter). You say that the requested skin substitute grafts (Q4133-Grafix prime, 
grafixpl prime, stravix and stravixpl, per square centimeter) is medically necessary. The Plan denied your 
request. The Plan says the requested skin substitute grafts (Q4133-Grafix prime, grafixpl prime, stravix and 
stravixpl, per square centimeter) 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 skin substitute grafts (Q4133-Grafix 
prime, grafixpl prime, stravix and stravixpl, per square centimeter). Our reviewer says that the requested skin 
substitute grafts (Q4133-Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter) is not 
medically necessary. Our physician reviewer found the record indicates that the enrollee has diabetic foot 
wounds in the setting of peripheral vascular disease. The record indicates that the enrollee has impaired peripheral circulation that has not been treated. The literature is insufficient to demonstrate the efficacy of the 
requested services for the enrollee's specific clinical condition. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. The requested service is not 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 skin substitute grafts (Q4133-Grafix prime, grafixpl prime, stravix and 
stravixpl, per square centimeter) have not been met. Therefore, we decided that the Plan does not have to pre-
approve skin substitute grafts (Q4133-Grafix prime, grafixpl prime, stravix and stravixpl, per square 
centimeter).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on September 4, 
2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the claim was submitted untimely. 
 
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 the emergency department visit was not filed until April 28, 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 the emergency department visit provided on 
September 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299) provided April 20, 2022 to 
April 27, 2022 . 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0299 is not supported in the medical record. Specifically, the claim was billed with an 
invalid type of bill. 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 pay for home health services 
(G0299) provided April 20, 2022 to April 27, 2022 .
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided on March 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for transportation services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says we did not receive proof of payment and per your 
evidence of coverage, the claim denied correctly. 
 
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 transportation services provided on March 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87640, 87653, 87798, and 
87801 billed for date of service November 4, 2021. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87640, 87653, 87798, and 87801. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 87481 is 
bundled into payment for code 87801. Payment for code 87640 is bundled into payment for code 87801. 
Payment for code 87653 is bundled into payment for codes 87801 and 87150. Payment for code 87798 is 
bundled into payment for code 87500. 
 
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 87481 
is a column II code to column I code 87801. We have confirmed that code 87640 is a column II code to column 
I code 87801. We have confirmed that code 87653 is a column II codes to column I codes 87801 and 87150. 
We have confirmed that code 87798 is a column II code to column I code 87500. This claim has not been billed 
with an appropriate modifier to bypass the edit. 
 
The documentation submitted does not include the laboratory report. The submitted medical records do not 
support that a repeat clinical laboratory test was performed. Therefore, code 87150 cannot be verified. 
The submitted medical records do not support a repeat clinical laboratory test was performed. Therefore, code 
87801 cannot be verified. 
 
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 codes 87150, 87481, 87640, 87653, 87798, and 87801 billed for date of 
service November 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the infusion into a vein for therapy, 
prevention, or diagnosis (96365) and injection of an additional drug or substance into vein (96375) provided on 
April 18, 2022. 
 
You asked the Plan to waive the copayment for the infusion and injection of an additional drug or substance. 
You say that the total amount billed was adjusted according to the maximum allowable Medicare guidelines, 
and the remaining maximum allowed charge of $237.87 was then billed to you. You also say that your 
understanding is that following the adjustment, insurance is applied and covers 80 percent, and 20 percent is 
billed to you as a copay. The Plan denied your request. The Plan says the cost share was applied correctly per 
your benefits. 
 
  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 a $250 
copay for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but 
not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $234.87, which is less than the standard $250 copayment for the infusion and 
injection of an additional drug or substance. The infusion and injection of an additional drug or substance falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 copayment for the infusion 
into a vein for therapy, prevention, or diagnosis (96365) and injection of an additional drug or substance into 
vein (96375) provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85060) provided September 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this service has a profession 
component / technical component indicator of 8. Payment for this service is included in payment to the 
hospital. 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 (85060) provided 
September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home Covid test kits (87426, S9999) provided on May 2, 
2022. 
 
You asked the Plan to pay for at-home Covid test kits. You say that the plan should reimburse you for the test 
kits. You read on the web that the federal government would pay for it. The Plan denied your request. The Plan 
says this particular benefit does not apply to Medicare Advantage members. 
 
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 at-home Covid test kits have not been met. Specifically, the requested test kits are not covered by 
the Plan. Therefore, we decided that the Plan does not have to pay for at-home Covid test kits (87426, S9999) 
provided on May 2, 2022.