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

 
We decided that the Plan does not have to pay for procedure code 45385 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 45385. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
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 45385 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 
procedure code 45385 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 45385 billed for date of service June 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vabysmo (J2777). 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vabysmo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
Vabysmo is not FDA-approved for the enrollee's diagnosis of central retinal vein occlusion. The requested use 
of this drug is not supported by any of the major drug compendia. Treatment is also not supported by a 
Medicare-approved medical journal. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Vabysmo (J2777).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 1, 2020. 
 
You asked the Plan to pay for the lab services. You say that you believed that the claim was submitted timely. 
The Plan denied your request. The Plan says this claim was not filed timely. 
 
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 lab services was not filed until September 15, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on July 1, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires trial of Remicade, Inflectra or Infliximab, and Stelara 
before it will approve Ilumya. 
 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 Ilumya. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Ilumya. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Remicade, Inflectra or Infliximab, and Stelara. 
The record does not show that these drugs would likely be less effective and/or 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Infuse BMP-2 allograft. 
 
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 Infuse BMP-2 allograft is approved for use only via an anterior or lateral approach 
and is only to be used with several specific devices. 
 
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 the health plan approved T2-pelvis posterior fusion, DePuy Synthes Expedium plates and screws, 
and inpatient stay. However, 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 this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Infuse BMP-2 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 the Infuse BMP-2 allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer/Vertiflex device 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. There is no discussion of scoliosis of the lumbar spine with no documentation of 
the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant 
osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at L4-5, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer/Vertiflex device
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk, you need IRF services to get 
your strength back. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
11, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost of manual manipulation of the spine (98941) and 
infrared therapy (97026) provided by an out-of-network chiropractor on March 22, 2022. 
 
You asked the Plan to pay the full cost of manual manipulation of the spine and infrared therapy provided by 
an out-of-network chiropractor. You say that you received a bill for these services. The Plan denied your 
request. The Plan says these services processed correctly. 
 The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation. The rules also 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 20% coinsurance for out-of-network Medicare-covered chiropractic services.  
 
The infrared therapy at issue is not manual manipulation of the spine, so it is not covered when provided by a 
chiropractor. You have been asked to pay a 20% coinsurance, or $8.33, for manual manipulation of the spine 
provided by an out-of-network chiropractor (41.66 allowed amount x 20% = $8.33). This item/service falls 
within the out-of-network Medicare-covered chiropractic services 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 pay the full cost of manual manipulation of the spine (98941) and infrared therapy (97026) provided by an 
out-of-network chiropractor on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for procedure code 99213. The Plan denied your request. The Plan says payment for 
code 99213 is bundled into payment for code 97597. 
 
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 99213 is a column II code to column I code 97597. 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 99213 billed for date of service June 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a gastroenterologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you went to the hospital with abdominal pain. 
At the emergency room (ER), they completed a colonoscopy. You would like a follow-up with the provider 
from the ER to discuss the results and surgery. The Plan denied your request. The Plan says you must use 
network providers to get your medical care and services. Since you already have a biopsy proven colon cancer, 
you need an expedited appointment with colorectal surgery vs surgical oncologist. In-network providers are 
available. 
 
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 (99204) with a gastroenterologist to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services billed with code 77067 for March 30, 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 18, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services billed with code 77067 for March 30, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99220) provided on April 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is an 
unbundled service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that code 99220 is unbundled. However, the Plan has not 
provided documentation showing that code 99220 was billed with another code that it is considered inclusive 
to. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the services (99220) provided on April 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was 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 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on November 22, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (27096, Q9966, J1030, & J1040) provided August 
10, 2022. 
 
You asked the Plan to pay for the injections. 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 27096, Q9966, J1030, & J1040 is not supported in the medical record. Specifically, the 
primary code billed has a status indicator of "B" and is not recognized under the outpatient prospective 
payment system. Based on this information, we decided that Medicare rules for coverage of the injections have 
not been met. Therefore, we decided that the Plan does not have to pay for injections (27096, Q9966, J1030, & 
J1040) provided August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services (92225, 92310) provided on June 10, 2022. 
 You asked the Plan to pay for vision services. You say that this was your annual vision exam, and you were 
told after the exam was provided that your doctor no longer accepts your insurance, but you could apply for 
reimbursement. You say that you did not purchase contacts at this exam. The Plan denied your request. The 
Plan says you previously received contact lenses on April 24, 2021, which means the services at issue exceed 
the limitations of your benefit. These services are covered once every 2 years. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam (eye refraction) every year and either standard lenses and 
frames or contact lenses once every 2 years. Contact lens fitting and evaluation may be an additional cost. 
 
We looked at the file and the Plan's rules. The services which were billed in this case include a contact lens 
fitting (92310) and a service which was not billed with a code recognized by Medicare, but is listed as, 
(Dilation) Extended ophthalmoscopy, initial (92225), per the providers billing statement. A contact lens 
fitting is not listed as a covered service under your supplemental vision benefit. The contract states that a 
contact lens fitting and evaluation may be an additional cost. In addition, services cannot be paid if they are 
billed incorrectly or with an unrecognized code. However, the service indicated, extended ophthalmoscopy, is 
not indicated as a covered service under your supplemental benefit and is not considered a routine eye exam or 
eye refraction. Based on this information, we decided that the Plan's rules for coverage of vision services have 
not been met. Therefore, we decided that the Plan does not have to pay for vision services (92225, 92310) 
provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 18, 2022, billed with 
codes 81210, 87235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
should be covered. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
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 18, 2022, billed with codes 81210, 87235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 
81194, and 81309.