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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires the services due to her current 
medical events. The Plan denied your request. The Plan says the records do not show that the enrollee requires 
daily skilled therapy. 
  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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted molecular pathology procedure (81479) provided 
on July 25, 2022. 
 
You asked the Plan to pay for an unlisted molecular pathology procedure. You say that you disagree with the 
denial and are requested reconsideration of payment on this claim. The Plan denied your request. The Plan says 
this specific test is not listed as a covered benefit with the Plan. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Review of the claim also shows that the requested test is not listed as a covered benefit with the 
Plan. Based on this information, we decided that Medicare rules for coverage of an unlisted molecular 
pathology procedure have not been met. Therefore, we decided that the Plan does not have to pay for an 
unlisted molecular pathology procedure (81479) provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 9, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional occupational therapy visits. 
 
You asked the Plan to pre-approve occupational therapy. You say that you are very weak and really need the 
occupational therapy right now to be able to get stronger to get around the house. The Plan denied your request. 
The Plan says 2 additional occupational therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
  
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 occupational therapy. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you do not require the unique skills of a professional 
therapist to safely and effectively provide treatment. The services can be safely and effectively performed only 
by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design or deliver a program to maintain your current condition to prevent or slow further deterioration. You can 
transition to an independent home exercise program and does not require the ongoing skills of a professional 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an ESI. You say that the requested injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements 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 an ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided imaging of the thoracic 
spine did not demonstrate foraminal or central spinal stenosis. Therefore, the reviewer found that the requested 
ESI is not 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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Percepta genetic testing provided on February 14, 2022. 
 
You asked the Plan to pay for the Percepta genetic testing. You say that this testing is covered per Medicare 
Local Coverage Determination L36886. The Plan denied your request. The Plan says that this claim was not 
submitted with a taxonomy code which is required by Plan guidelines. As such, no payment can be made. 
 
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 sole rationale for denial of payment of this service was a missing taxonomy 
code on the claim. However, the Plan did not provide a copy of the claim to verify this is true. In addition, there 
is no Medicare billing rule which requires reporting of taxonomy codes on professional claims, as the 
taxonomy is associated with the National Provider Identifier (NPI) number. We find that the denial of payment 
is not supported in this case. Therefore, we decided that the Plan has to pay for the Percepta genetic testing 
provided on February 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment; therefore, these services should be paid 
separately. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided August 16, 
2022. 
 
You asked the Plan to pay for the emergency visit. You say that the enrollee had multiple exams on the same 
date of service and the records support the services billed. 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 August 30, 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 the emergency visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided 
August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (Q4049 and G0463) provided on August 
13, 2022. 
 
You asked the Plan to pay for outpatient services. You say that this claim was billed correctly, and these 
services are supported in the medical records. The Plan denied your request. The Plan says this claim has an 
Integrated Outpatient Code Editor (I/OCE) edit errors, and this claim cannot be paid until this information is 
corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that when an outpatient claim is submitted with a 
code that is not recognized by Medicare for OPPS, the entire claim is denied and returned to the provider for 
correction.  
 
We looked at the file and Medicare rules. Code Q4049 has an OPPS status indicator of B  Codes that are not 
Recognized by OPPS. This claim is an outpatient claim which is subject to I/OCE edits. Edit 62 applies in this 
case, and therefore this claim is denied and must be corrected for payment. Based on this information, we 
decided that Medicare rules for coverage of outpatient services have not been met. Therefore, we decided that 
the Plan does not have to pay for outpatient services (Q4049 and G0463) provided on August 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a spring-powered device for lancets (A4258) provided on 
May 28, 2022. 
 
You asked the Plan to pay for a spring-powered device for lancets. You say that both the prescription and 
medical records clearly indicate the medical necessity for the requested item. The Plan denied your request. 
The Plan says the plan is upholding the denial as the provider did not bill as required by Medicare coding 
regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file and Medicare rules. The records show the provider billed for a spring-powered device for 
lancets on March 9, 2022. The LCD confirms that more than one spring powered device per 6 months is not 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a spring-
powered device for lancets have not been met. Therefore, we decided that the Plan does not have to pay for a 
spring-powered device for lancets (A4258) provided on May 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the shoulder. 
 
You asked the Plan to pre-approve an MRI of the shoulder. 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 must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the shoulder. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case, the record 
indicates that the enrollee has shoulder pain reportedly for two months. The record does not indicate the 
presence of red flag symptoms or physical examination findings. Plain X-rays are reported as normal. The 
record does indicate that the enrollee has had a failure of conservative therapy. The requested service is not 
medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this 
time. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 an MRI of the shoulder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the shoulder.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
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 83789 
is a column II code to column I code G0480. 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.  The Plan paid code 
G0480. This procedure code specifically includes mass spectrometry and chromatography. The provider billed 
CPT code 83789 with modifier 59 to indicate that a separate and distinct chromatography and mass 
spectrometry was performed. The Provider says that CPT Code 83789 represents validity testing to confirm the 
results of the drug tests performed. The Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory 
performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine 
specimen is not adulterated, this testing is not separately billed. Therefore, we decided that the Plan does not 
have to pay for procedure code 83789 billed for date of service June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88141, 88175) provided on August 11, 
2022. 
 
You asked the Plan to pay for the pathology services. You say that these services were 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 codes 88141, & 88175 are not supported in the medical record. Specifically, these codes 
have a professional component / technical component indicator of 2 and were incorrectly billed with modifier 
26. Based on this information, we decided that Medicare rules for coverage of the pathology services have not 
been met. Therefore, we decided that the Plan does not have to pay for pathology services (88141, 88175) 
provided on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incentive spirometer device (A9284). 
 
You asked the Plan to pre-approve an incentive spirometer device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an incentive spirometer device (A9284).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (E2300, E2301, E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that bilateral upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary.  
 
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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient is non-ambulatory and requires a power wheelchair for mobility and performing her basic 
daily activities. She cannot perform pressure relief independently due to weakness and spasticity and requires a 
power wheelchair with power tilt and recline for adequate pressure relief and positioning. She also requires 
power elevating leg rests for positioning and her lower extremity spasticity. The complexity of her seating and 
positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller with 
harness and electronic connection are necessary to operate the group 3 power wheelchair base and the power 
tilt and recline and power elevating leg rests via a joystick. Therefore, the expandable controller with harness 
and electronic connection is 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 the accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (E2300, E2301, E2311, E2313, E2377).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this has been approved under Part D. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a triluron injection provided on June 20, 
2022. 
 
You asked the Plan to waive the cost sharing for a triluron injection. You say that the enrollee cannot afford to 
pay this as they are on a fixed income. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B chemotherapy drugs and 20% coinsurance for other Medicare 
Part B drugs.  
 
 
 
 The enrollee has been asked to pay $330 for a triluron injection ($1,650 x 20% = $330). This item/service falls 
within the Medicare Part B drugs benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost 
sharing for a triluron injection provided on June 20, 2022.