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

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine study provided on May 
26, 2022. 
 
You asked the Plan to waive the copayment for a nuclear medicine study. You say that the services provided 
were to diagnose the condition of your lungs due to COVID damage. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 $325 
copayment for nuclear medicine services. 
 
You have been asked to pay a $325 copayment for a nuclear medicine study. This item/service falls within the 
nuclear medicine 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 waive the copayment for a nuclear medicine study provided on May 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed.

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0180 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code G0180. You say that the services were provided in good faith. 
The Plan denied your request. The Plan says payment for code G0180 is bundled into payment for code 99337. 
 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 G0180 is a column II code to column I code 99337. 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 G0180 
billed for date of service April 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service December 2, 
2021, to December 10, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that the code is valid. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9500 billed for date of service December 2, 2021, to December 10, 2021.
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 June 2, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the qualifying circumstances enable this 
code to be payable. The Plan denied your request. The Plan says procedure code 99100 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 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service June 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 23, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calquence.

You asked the Plan to pre-approve Calquence. 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 Calquence. 

Benefits for Calquence 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).

You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollee's chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L1-2, L2-3, and 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for physician/practitioner service and Medicare 
Part B drug provided on April 24, 2021. 
 
You asked the Plan to waive the cost share for physician/practitioner service and Medicare Part b drug. You 
say that you are requesting reconsideration stating you have been trying to settle this account since the fall of 
2021. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $25 
copayment for specialist's office.  
 
Your contract with the Plan clearly says that you must pay 20% coinsurance for part B drug. The allowed 
amount of this injection total $0.64, resulting in a total coinsurance amount of $0.13. 
 You have been asked to pay $25 copayment for physician/practitioner service and 20% coinsurance for 
Medicare Part b drug. This item/service falls within the specialist's office benefit and Medicare Part B covered 
drugs 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 cost share for physician/practitioner service and Medicare 
Part B drug provided on April 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 28, 
2022, through June 1, 2022. 
 You asked the Plan to pay for SNF care. You say that the admission to a SNF was medically necessary. The 
Plan denied your request. The Plan says the admission to a SNF was not medically necessary. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not require skilled nursing or therapy services on a daily basis. The 
enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 28, 2022, through June 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing visits (G0299), and hospice or home 
health care provided in assisted living facility (Q5002) provided on February 17, 2022. 
 
You asked the Plan to pay for the hospice services. You say that the enrollee's hospice election was revoked on 
February 12, 2022. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
visits (G0299), and hospice or home health care provided in assisted living facility (Q5002) provided on 
February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).

You asked the Plan to pre-approve a semi-electric hospital bed. You say that this is medically necessary. The Plan denied your request. The Plan says you do not need frequent or immediate changes in body position.

The Plan follows Medicare rules. Medicare rules say that  a semi-electric hospital bed (E0260) is covered if the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.

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 semi-electric hospital bed. Our reviewer says that the requirements for coverage of a semi-electric hospital bed have not been met. Our physician reviewer found although there is documentation that you are weak and unsteady, there is no documentation that you require frequent changes in body position or have an immediate need for a change in body position.

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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided on February 2, 2022, to February 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON dialysis services. You say that your organization provided medically 
necessary care. The Plan denied your request. The Plan says unauthorized, out-of-network services are not 
covered. 
 
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 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 dialysis services provided on February 2, 2022, to 
February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes G0463, J7040 and M0247 billed for date of service January 27, 2022.

You asked the Plan to pay for procedure codes G0463, J7040 and M0247. You say that the services at issue have been billed correctly. The Plan denied your request. The Plan says the codes in this case are not correctly billed.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. Medicare rules also say that modifiers may be appended to procedure codes only if the clinical circumstances justify the use of the modifier. Modifier 25 may be appended to an E&M CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service.

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 procedure code G0463. Our reviewer says that procedure code G0463 does not meet criteria for payment in this case. Our physician reviewer found that the medical record describes outpatient hospital services for infusion and assessment. In this case, modifier 25 would be appropriate for clinic visit/assessment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code G0463 have not been met.

We find that procedure code J7040 has a Status Indicator of E on the Physician Fee Schedule and that procedure code M0247 has a Status Indicator of X. This means that procedure codes J7040 and M0247 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes J7040 and M0247 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes G0463, J7040 and M0247 billed for date of service January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.

You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients that meet certain criteria.

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 percutaneous vertebral augmentation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) dated September 22, 2022, showed severe wedging of the L5 vertebral body with associated bone marrow edema and retropulsion of the posterior aspect of the L5 vertebral body. These findings are relative contraindications for the requested procedure. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of a continuous positive airway pressure (CPAP) device (E0601RR) and humidifier (E0562).

You asked the Plan to pre-approve continuation of a CPAP device and humidifier. You say that the device is medically necessary due to obstructive sleep apnea (adult) (pediatric). The Plan denied your request. The Plan says the documentation shows you have not been compliant with the use of the Positive Airway Pressure (PAP) device and the coverage criteria has not been met.

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 continuation of a CPAP device and humidifier. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you meet the coverage criteria established by LCD L33718. The case file does not contain documentation of an in-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are improved, nor does it contain documentation of adherence to therapy, defined as use of PAP =4 hours per night on 70% of nights during a consecutive thirty day period anytime during the first three months of initial usage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of a CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of a continuous positive airway pressure (CPAP) device (E0601RR) and humidifier (E0562).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.

You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria have not been met.

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 genicular nerve radiofrequency
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found in this case; the record indicates that the enrollee has
osteoarthritis of the knee. There is insufficient literature to support the safety and efficacy of the requested
service 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 genicular nerve radiofrequency ablation have not been met. Therefore, we
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.