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

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on July 22, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 10, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on July 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional physical therapy visits. 
 
You asked the Plan to provide additional physical therapy visits. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the details we got from your 
doctor dont meet Medicare guidelines that show a medical reason you need twelve additional outpatient 
physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits 
have not been met. Therefore, we decided that the Plan does not have to provide additional physical therapy 
visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fractional Flow Reserve (FFR) testing. 
 
You asked the Plan to pre-approve Fractional Flow Reserve (FFR) testing. You say that the requested 
Fractional Flow Reserve (FFR) is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the Fractional Flow Reserve (FFR) requested. 
 
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 Fractional Flow Reserve (FFR). Our 
reviewer says that the enrollee does not meet criteria for the Fractional Flow Reserve (FFR) requested. Our 
physician reviewer found at issue is the appropriateness and medical necessity of carrying out FFRct in 
evaluation of this enrollees symptoms. A stress test has been performed previously. This technique is based on 
computer-assisted processing of coronary computed tomography (CT) angiography images to estimate 
coronary blood flow changes related to coronary artery stenosis. It is only performed if baseline CT 
angiography shows a borderline stenosis. This enrollee has not had a baseline coronary CT angiogram. As such 
it cannot be established that he is a candidate for FFRct. In summary, the requested testing is not considered 
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 Fractional Flow Reserve (FFR) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Fractional Flow Reserve (FFR) testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar spinal surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
June 6, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you feel the hearing aids should be covered. You 
say you trusted the doctor. The Plan denied your request. The Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received by the network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on June 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint (64636). 
 
You asked the Plan to pre-approve RFA for SI joint. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
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 RFA for SI joint. Our reviewer says 
that the requested RFA for SI joint is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested service has not been proved effective. The reviewer found that this 
service is considered experimental. Therefore, the reviewer found that RFA for the SI joint 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 RFA for SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint (64636).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on January 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that the enrollee is in a dual Plan and they should be 
covered under Medicaid benefits. The Plan denied your request. The Plan says the services were provided by 
an out-of-network provider. The services are available in the network of providers of the Plan. 
 
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 outpatient services provided on January 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76770 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 76770 
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 76770 billed for date of service August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81206, 81235, 81301, 81162, 81292, 81295, 81298, 81317, 81321, 81402, 81194, and 8130. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 1, 2022, billed with codes 81206, 81235, 81301, 81162, 81292, 81295, 81298, 81317, 81321, 81402, 
81194, and 8130.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services, an evaluation and management service, 
and administration of nutri-pharmaceutical blends provided on February 17, 2021. 
 
You asked the Plan to pay for practitioner services and nutri-pharmaceuticals. You say that you performed 
these services in good faith. The Plan denied your request. The Plan says these services are not covered by 
Medicare.  
The Plan must follow Medicare rules. Medicare rules say that outpatient physical therapy services are only 
covered if they are furnished by or under the direct supervision of a physical therapist; or by, or incident to the 
service of a nurse practitioner or physician assistant that may perform physical therapy services under state law. 
Medicare rules say that modifier -25 is defined as a significant, separately identifiable evaluation and 
management service. Medicare rules say that claims for compounded drugs shall be submitted using a 
compounded drug, not otherwise classified code. 
 
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide 
physical therapy in the State of Ohio. The office visit at issue was billed with modifier 25, which is used to 
report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or 
other qualified health care professional on the same day of a procedure or other service. There is no 
documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the 
enrollee on this date of service. The multiple drug codes reported on this claim refer to a pre-filled compounded 
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified 
code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are 
not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we 
decided that Medicare rules for coverage of therapy services and nutri-pharmaceuticals have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic services, an evaluation and 
management service, and administration of nutri-pharmaceutical blends provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure code U0003 billed for date of 
service January 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that time-sensitive medically necessary tests were 
performed. The Plan denied your request. The Plan says the documentation does not support the services. 
 
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 additional units CPT code U0003 is not supported in the medical record. Specifically, the records 
do not show the physicians intent or necessity for additional units to be performed. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for additional units of procedure code U0003 billed for date of service 
January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
provided on December 15, 2020. 
 
You asked the Plan to pay for the resin-based composite - two surfaces, posterior (D2392). The Plan denied 
your request. The Plan says at the time of the date of service the enrollee did not have supplemental dental 
coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for resin-based composite - two 
surfaces, posterior (D2392) provided on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the level of care that 
the LTACH provides. The Plan denied your request. The Plan says the Medicare guidelines for LTACH 
admission were not met and the enrollee is receiving the proper care at the current inpatient hospital. 
 
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. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64483 and 64484 billed for date of service 
October 25, 2021. 
 
You asked the Plan to pay for procedure codes 64483 and 64484. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that providers or suppliers 
shall use anatomic modifiers and report procedures with differing modifiers on individual claim lines when 
appropriate. 
 
In this case, code 64483 has not been billed with a requisite anatomic modifier. Additionally, we have 
confirmed that code 64484 is an add-on code and has not been billed with an appropriately reported primary 
procedure code. 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 codes 64483 and 64484 billed for date of service 
October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix glucose test strips. 
 
You asked the Plan to pre-approve True Metrix glucose test strips. You say that these non-preferred test strips 
are necessary over the Plan's preferred test strips. The Plan denied your request. The Plan says there is no 
medical necessity for the non-preferred test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of True Metrix glucose test strips have 
been met. Specifically, no medical records were submitted that support why the Plans preferred brand of test 
strips would not be sufficient for the enrollees condition. Therefore, we decided that the Plan does not have to 
pre-approve True Metrix glucose test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you test your blood sugar 10 times daily. The 
Plan denied your request. The Plan says the criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on August 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you believe this should be covered and 
approved for payment. The Plan denied your request. The Plan says these drugs are not covered under your 
medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on August 17, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.