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

 
We decided that the Plan does not have to pre-approve Visudyne. 
 
You asked the Plan to pre-approve Visudyne. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Visudyne. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of the 
ophthalmic formulation of bevacizumab before they will approve the requested drug. The documentation does 
not indicate the enrollee has tried and failed the required drug. In this case, the documentation does not support 
that Bevacizumab would likely be less effective, and/or would likely 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 Visudyne have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visudyne.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood count (85025) comprehensive metabolic panel (80053) 
lipid panel (80061) thyroid-stimulating-hormone (84443) provided on January 12, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that this enrollee was experiencing many health 
issues, it was necessary for the lab to ensure there are no medical concerns that would severely impact the 
health of the enrollee. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 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 blood count (85025) comprehensive metabolic 
panel (80053) lipid panel (80061) thyroid-stimulating-hormone (84443) provided on January 12, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on October 12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that these codes are reimbursed to anesthesia providers only. 
 
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 has not provided a valid rationale for why the rendering provider type 
is not appropriate for anesthesia services. The provider has stated that they were attaching a registry form to 
confirm that the provider was certified at the time of service. The plan has not provided this document for us to 
review. Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on 
October 12, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided on February 8, 2022. 
 
You asked the Plan to pay for the services provided. You say that the place of service is billable with the code. 
The Plan denied your request. The Plan says treatment was rendered in an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of Code 90935 is Hemodialysis procedure with single evaluation 
by a physician or other qualified health care professional. 
 
The file shows the enrollee received dialysis services in an outpatient hospital facility. The diagnosis code 
billed, N18.6, is defined as end stage renal disease (ESRD). CPT code 90935 is used to report outpatient 
hemodialysis performed on non-ESRD patients.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the dialysis services provided on February 8, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 5, 2021, 
to November 16, 2021. 
 
You asked the Plan to pay for the home health services. You say that the provider's office does not have access 
to send the claims electronically. You also say that you should not be penalized for post office issues. The Plan 
denied your request. The Plan says no exception request was submitted to waive the 5-day requirement for 
filing the RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 5, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided from November 5, 2021, to November 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet blocks are covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you underwent previous cervical facet 
injections and there is no documentation that you cannot undergo a radiofrequency ablation (RFA) procedure. 
There is no indication that you have a condition that would not allow for RFA, such as a pacemaker or 
defibrillator. The additional facet blocks are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. 
 
  
 Therefore, we decided that the Plan does not have to pre-approve facet block injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99231) provided June 14, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed has a bundled relationship with another service 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. In this case, we have confirmed that code 99231 has a bundled relationship with code 54161. 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 physician services (99231) provided June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen 
concentrator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that oxygen equipment is covered when specific 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had COVID-19 some 
months ago and was prescribed oxygen at that time. This is apparently a renewal request. She reports oxygen 
desaturation at home, but resting and exercise pulse oximetry in the office show adequate oxygenation (95 
percent or greater on room air). The criteria for coverage are not met and the services are therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator and portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on January 8, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on January 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nervous system function test (95922) provided on August 
5, 2021. 
  You asked the Plan to pay for the nervous system function test (95922). You say that the attached medical 
records should be reviewed as they prove medical necessity. The Plan denied your request. The Plan says a 
modifier is not allowed with this code pair. 
 
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 95922 
is a column II code to column I code 95921 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the nervous system function test (95922) provided on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-elastic binder for extremity (A4465). 
 
You asked the Plan to pre-approve a non-elastic binder for extremity. You say that this item is medically 
necessary for your condition. The Plan denied your request. The Plan says this item is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-elastic binder for an extremity (A4465) is 
an example of a wound care item which is non-covered under the surgical dressing benefit because it does not 
meet the statutory definition of a dressing. Based on this information, we decided that Medicare rules for 
coverage of a non-elastic binder for extremity have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-elastic binder for extremity (A4465).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided November 4, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you didn't need to go to the hospital 
because you were feeling better. The Plan denied your request. The Plan says this service is not covered when 
there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on November 4, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81292, 81301) provided October 18, 
2021. 
 
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 the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81292, 81301) provided 
October 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided July 28, 
2021. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you were very ill and should not 
have to pay this extra cost. The Plan denied your request. The Plan says this service is not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.  
 Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services (A0432) provided July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026), ultraviolet therapy (96365), and 
intravenous infusion (96365), provided on August 26, 2021, to September 18, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the infrared therapy, ultraviolet therapy, and intravenous infusion. You say that 
the service should be covered. The Plan denied your request. The Plan says this service is not covered when 
obtained out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026), ultraviolet therapy 
(96365), and intravenous infusion (96365), provided on August 26, 2021, to September 18, 2021 by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flex-walk system or equal and multiaxial rotation unit 
(K3 level components). 
 
You asked the Plan to pre-approve flex-walk system or equal and multiaxial rotation unit. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that K3 components are only covered for certain 
indications. 
 
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 flex-walk system or equal and 
multiaxial rotation unit. Our reviewer says that the documentation does not support that the requested items are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a foot wound and 
osteomyelitis with a left below-the-knee amputation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flex-walk system or equal and multiaxial rotation unit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve flex-walk system or equal and multiaxial 
rotation unit (K3 level components).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided on October 4, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says that this claim was billed with an office POS code, but the sample was not 
taken in an office setting but rather at the assisted living facility. 
 
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 documentation submitted is not sufficient to determine that this sample was 
taken at the enrollee's home or assisted living facility. This claim was billed with an office POS code, and we 
find that the file does not clearly show this is incorrect. The denial of payment based solely on the POS code 
reported is not substantiated. Therefore, we decided that the Plan has to pay for the lab testing provided on 
October 4, 2021.  
 
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 (81206, 81301, 81311) provided October 10, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the 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 a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81301, 81311) provided 
October 10, 2021.