Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (T1021). 
 
You asked the Plan to pre-approve the home health services. You say that you have having difficulties walking. 
The Plan denied your request. The Plan says the requested home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health service is not medically necessary. Our physician reviewer found there is 
insufficient clinical documentation regarding the necessity of home health aide services. The reviewer found 
that you have difficulty ambulating, but the level of function in terms of mobility and the need for an assistive 
device is not provided. The reviewer found that the physical examination is limited and does not address motor 
strength and range of motion in your lower extremities. Therefore, the reviewer found that the requested home 
health aide services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home health aide (T1021).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 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 procedure code 70450 billed for date of service April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Humira pen. 
 
You asked the Plan to pre-approve Humira. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Humira pen.  
 
  Benefits for Humira 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography (92250) provided on May 4, 2022. 
 
You asked the Plan to pay for fundus photography. You say that you want the Plan to pay for this service. The 
Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of fundus photography have not been met. Specifically, the service at issue is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for fundus photography (92250) provided on May 4, 
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 April 6, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. 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 April 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of lumbar foraminal stenosis and degenerative disc disease has not been demonstrated in the peer-
reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX-Z Code must be reported 
for a molecular diagnostic test.  
 
We looked at the file and Medicare rules. The requested testing was not billed with an appropriate DEX-Z 
Code. A DEX-Z Code is required for payment to be considered. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Respiratory Pathogen Panel Testing provided on April 
12, 2021. 
 
You asked the Plan to pay for the Respiratory Pathogen Panel Testing. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. The rules say that panels with greater than 5 respiratory pathogens are 
considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the Respiratory Pathogen Panel Testing provided 
on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy or excision of lymph node(s) services coded 
38525 provided on January 27, 2022. 
 
You asked the Plan to pay for the biopsy or excision of lymph node(s) services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 38525. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the biopsy or excision of lymph node(s) services have not been met. Therefore, we decided that the Plan does not 
have to pay for the biopsy or excision of lymph node(s) services coded 38525 provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested durable 
medical equipment will not be covered by Medicare as the member resides in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus (J2350). 
 
You asked the Plan to pre-approve Ocrevus. You say that you recommend the enrollee be treated with Ocrevus 
because it is more appropriate to treat their particular case and prevent further health decline. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred product, Kesimpta. The Plan also 
says that there is no documentation of intolerance or contraindication to Kesimpta. 
 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 Ocrevus. Our reviewer says that 
Ocrevus is not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried and 
failed the required drug, Kesimpta. Our reviewer also found that the documentation does not support that 
Kesimpta 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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus (J2350).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you don't understand why this isn't covered. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided April 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the genicular nerve block (64454) provided on January 24, 2022. 
 
You asked the Plan to pay for the injection. You say that procedure code 64454 is payable when diagnosis code 
G89.18, other acute post-procedural pain, is used. You also say that you expect to be paid accordingly. The 
Plan denied your request. The Plan says that the provided documentation does not support the necessity of the 
service in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the injection. Our reviewer says that the 
requested injection is considered medically reasonable and necessary in this case. Our physician reviewer 
found the provision of post-operative pain relief is medically reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pay for 
the genicular nerve block (64454) provided on January 24, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on 
January 18, 2022. 
 
You asked the Plan to waive the copayment for a physical therapy visit. You say that you cannot afford this 
copayment and therefore would like it to be waved. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for a physical therapy visit. A physical therapy visit falls within 
the Outpatient Rehabilitation 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 
physical therapy visit provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device rendered on October 19, 2021. 
 
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 there is no face-to-face encounter. 
 
The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the 
beneficiary and their treating physician is required prior to prescribing durable medical equipment (DME). 
 
We looked at the file and Medicare rules. The file shows that there is no valid face-to-face encounter for the 
DME. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve 
stimulation (TENS) device rendered on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Omnipod. 
 
You asked the Plan to pre-approve Omnipod. You say that the requested treatment is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Omnipod.  
 
  Benefits for Omnipod 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: 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 January 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is not a contractual 
agreement to include this in the dialysis rate. 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 January 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on August 16, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, payment for this code is 
inclusive in the diagnosis-related group (DRG) payment to the acute care hospital. This means this code is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81479 provided on August 16, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing provided on February 15, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes this gene, 
the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. Medicare rules say that the F1CDx panel is covered when provided 
for an FDA-approved indication. No other valid denial rationale was presented by the Plan. Based on this 
information, we decided that Medicare rules for coverage of F1CDx testing have been met. Therefore, we 
decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing provided on February 15, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services and COVID-19 
testing provided on December 30, 2021. 
 
You asked the Plan to pay for the ED and COVID testing services. You say that this claim should be paid. The 
Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that freestanding EDs not affiliated with hospitals are 
generally not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Medicare has allowed freestanding EDs to enroll in Medicare as 
temporary hospitals during the COVID-19 public health emergency, there was no evidence submitted to 
support that this provider has done so. Based on this information, we decided that Medicare rules for coverage 
of the ED and COVID testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the emergency department (ED) services and COVID-19 testing provided on December 30, 2021.