Persius/hicric huggingface dataset:
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 1, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you disagree with the Plan's denial. 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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service August 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for 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 the criteria for coverage for Ilumya. Our physician reviewer found the health plan 
requires that Infliximab be tried and failed. There is no evidence that the enrollee is allergic to or intolerant of 
Infliximab. Our reviewer found that there is no evidence that the enrollee has tried and not responded to 
Infliximab. There is no documentation as to why Infliximab would not be expected to be safe and effective for 
the enrollee. Our physician reviewer also found that the requested medication is not shown to be currently 
medically necessary and reasonable. 
 
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 Ilumya (J3245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 We looked at the file and Medicare rules. Procedure code 99213 was billed on the same day by a physician in 
the same group practice and same specialty as code 13160. Code 99213 was not billed with a modifier to allow 
for separate payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on 
August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 15823 and 67900 billed for date of service 
January 28, 2022. 
 
You asked the Plan to pay for procedure codes 15823 and 67900. You say that the services at issue have been 
billed correctly. 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 codes 15823 and 67900 is 1. The MAI value for these codes is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 15823 and 67900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 15823 and 67900 billed for date of service January 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Orthofix Trinity Elite allograft (20930) and Bone 
Marrow Aspirate (20939). 
 
You asked the Plan to pre-approve the Orthofix Trinity Elite allograft and Bone Marrow Aspirate. You say that 
these services are medically necessary. The Plan denied your request. The Plan says these services are 
considered experimental. 
 
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 Orthofix Trinity Elite allograft and 
Bone Marrow Aspirate. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found these services are considered experimental. 
 
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 Orthofix Trinity Elite allograft and Bone Marrow Aspirate have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Orthofix Trinity Elite allograft 
(20930) and Bone Marrow Aspirate (20939).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the laboratory services and testing (81002, 84403, 
80061, 83036, 83540, 82728, 82306, 82746, 82607, 84550, 80053, 85025, 99397, 92567, 92552, 99214, 
93000) provided on July 14, 2022. 
 
You asked the Plan to waive the deductible for the services at issue. You say that you confirmed with the Plan's 
customer service agent that this provider is in-network, but the Plan processed this claim as out-of-network and 
applying your deductible even though this was your annual wellness exam with an in-network provider. The 
Plan denied your request. The Plan says that you are responsible for a $1,000 deductible, which applies to the 
services at issue. 
 
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. Specifically, the Plan has not acknowledged nor addressed your grievance 
regarding the network status of this provider. You state that an agent of the Plan informed you that this 
provider is in-network. The Plan has not provided any evidence to show that this provider is out-of-network, 
nor has the Plan provided any evidence to show that you were not given this information by a Plan 
representative. In addition, the Plan has not provided any documentation to show that you had not already met 
your deductible in 2022. The Plan has failed to support their decision to apply a deductible to these services. 
Therefore, we decided that the Plan has to waive the deductible for the laboratory services and testing (81002, 
84403, 80061, 83036, 83540, 82728, 82306, 82746, 82607, 84550, 80053, 85025, 99397, 92567, 92552, 99214, 
93000) provided on July 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with power seating system, 
tilt only and accessories. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with power seating system, tilt only and 
accessories. The Plan denied your request. The Plan says the request for this group 2 power wheelchair with 
power options does not meet medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with power seating 
system, tilt only may be covered if certain criteria are met. 
 
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 Group 2 power wheelchair with 
power seating system, tilt only and accessories. Our reviewer says that the enrollee does not meet the Medicare 
criteria for the requested Group 2 power wheelchair with power seating system, tilt only. Our physician 
reviewer found the enrollee is independent with their current device. Our reviewer also found that the enrollee 
does not use intermittent catheterization, have high risk for skin breakdown, or have spasticity. 
 
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 Group 2 power wheelchair with power seating system, tilt only and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 
power wheelchair with power seating system, tilt only and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you need this benefit. The Plan denied your 
request. The Plan says you do not have a need for intensive case management and is not a high risk for 
hospitalization. The Plan also says that the requirements for the SSBCI program have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of the 
eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82656, 83520) provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (82656, 83520) provided on July 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 30, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and was reported correctly. 
The Plan denied your request. The Plan says that the reported code is not supported in this case. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records show that between 
15 and 21 drug classes were tested in this case, including alcohol biomarkers, amphetamines, benzodiazepines, 
buprenorphine, cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, 
methylenedioxyamphetamines, opiates, opioids and opiate analogs, oxycodone, phencyclidine, pregabalin, 
skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on August 30, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visual field assessment monitoring 
(ForeseeHome device) (0379T). 
 
You asked the Plan to pre-approve a ForeseeHome device. You say that you would like the denial to be 
reversed and for the services to be approved. The Plan denied your request. The Plan says the ForeseeHome 
device for home visual field monitoring in macular degeneration is still being studied to see if the service is 
reasonable and necessary. The Plan also says there is lack of evidence to support ForeseeHome over traditional 
visual field self-monitoring. 
 
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 a ForeseeHome device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Foresee Home Age-Related Macular Degeneration monitoring program is 
considered investigational/experimental as additional clinical studies are needed to demonstrate that it affects 
visual outcomes. 
 
 
 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 ForeseeHome device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home visual field assessment monitoring (ForeseeHome device) (0379T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not have the support to be safely discharged 
to home. The Plan denied your request. The Plan says you do not meet Medicare guidelines for IRF services. 
 
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 upon review of the available records, you do not meet coverage criteria for an 
IRF admission. The documentation does not support necessity for admission to an IRF and the complexity of 
your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. While you may have a need for physical therapy and/or 
occupational therapy, your rehabilitation needs can be provided in a lower intensity and alternate setting such 
as in a skilled nursing facility. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3, power wheelchair and accessories including 
power options (K0856, E2311, E2313, E2377, E2310, E2361, E1002, E0955, E1028x2, E2615, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not 
have medical need for single power options included with a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
past medical history including diabetes mellitus, hypertension and previous strokes with left sided weakness. 
The documentation indicates the enrollee has 4/5 bilateral upper extremity strength and that he has difficulty 
with ambulation and frequent falls. There is no documentation to support the enrollee is at high risk for skin 
breakdown or injuries. The enrollee has a neurologic disorder with functional deficits. The documentation does 
not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder that 
would necessitate power tilt or recline. Although the enrollees condition may meet criteria for a power 
wheelchair, the criteria for this specific wheelchair with multiple power options including power tilt and recline 
are not met. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3, power wheelchair and accessories including power 
options (K0856, E2311, E2313, E2377, E2310, E2361, E1002, E0955, E1028x2, E2615, E2607).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Lucentis. Our reviewer says that the 
documentation does not support the requested drug meets step therapy criteria. Our physician reviewer found 
the enrollee has macular edema following retinal vein occlusion. The documentation does not support that the 
enrollee has tried and failed Avastin/bevacizumab. The documentation does not support that 
Avastin/bevacizumab would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your physicians have informed you that you meet the 
qualifications to transfer to an IRF for your necessary recovery care. The Plan denied your request. The Plan 
says the IRF services requested do not meet the requirements for approval. 
 
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 do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have had a decline 
from your baseline level of function and would likely benefit from therapy, but you do not require the intensity 
of therapies provided on acute inpatient rehabilitation. 
 
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 IRF admission and services.