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

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on 
September 4, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that the patient's condition was such that the time needed to transport a patient 
by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously 
endangered the patient's health. The patient had a stable L2 burst fracture and had no focal neurologic deficits. 
The pain level was recorded as 3/10. Ground transportation would have been a reasonable means of 
transport. The documentation does support that the transferring hospital did not have adequate facilities to 
provide the medical services needed by the patient. Transportation to a different facility was medically 
necessary and ground transportation would have been a safe means of transport.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on September 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 22, 
2022. 
 
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 this was not reported correctly. 
 
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 31645 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 the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services 
provided to the enrollee on February 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76700 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 76700 
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 76700 billed for date of service April 1, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on June 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
records support that services were rendered on the billed date of service. The Plan denied your request. The 
Plan says that the enrollee was deceased on this date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the records clearly indicate that the enrollee was not deceased on 
the billed date of service. The medical records indicate that the enrollee called the ambulance on the billed date 
of service and that the enrollee was transported to the hospital on this date. Therefore, we decided that the Plan 
has to pay for ambulance services provided on June 8, 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 the genetic testing provided on November 15, 2021, billed 
with codes 81406, 81407, 81408, 81479, 81284, and 81286. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
November 15, 2021, billed with codes 81406, 81407, 81408, 81479, 81284, and 81286.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service January 2, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the patient had multiple exams on this date 
of service. 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 2, 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 March 25, 
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 March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70547 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 70547. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70547 is bundled into payment for code 70540. 
 
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 70547 
is a column II code to column I code 70540. 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 70547 billed for date of service March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 74018 is bundled into payment for code 74250. 
 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 74018 
is a column II code to column I code 74250. 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 74018 billed for date of service April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
received on August 20, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you believe the Plan has a $0 copayment 
for diagnostic radiology services. The Plan denied your request. The Plan says this copayment 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). Your contract with the Plan clearly says that you must pay a $50 
copayment for radiological diagnostic services (not including x-rays).  
 
You have been asked to pay a $50 copayment for the MRI. The MRI falls within the radiological diagnostic 
services (not including x-rays) 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 
the magnetic resonance imaging (MRI) you received on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided from February 3, 2022, to April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you spoke with a Plan rep and was advised that all of 
your doctors and medicines would be covered. You also say that you are now receiving bills from your doctors 
and other medical expenses that have gone unpaid. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan. The Plan also says that they have also determined that these services are 
not urgent or emergent, nor were they approved in advance. 
 
 
 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 drug testing provided from February 3, 2022, to 
April 11, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found  
 
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 Orthovisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Oxycodone.  
 
Benefits for Oxycodone 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 Botox 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 has a diagnosis of 
gastroparesis. This is not a medically-accepted indication for Botox, per the Medicare criteria. 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 Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided from October 1, 2021, to 
October 15, 2021. 
 
You asked the Plan to pay for the outpatient services. 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. Medicare rules say that providers must report services correctly. 
 
Outpatient services furnished to a beneficiary more than 3 days preceding the date of the beneficiarys 
admission to the hospital, by law, are not part of the payment window and must not be bundled on the inpatient 
bill with other outpatient services. The record shows that the services at issue were performed outside of the 3-
day inpatient window. The services would therefore need to be billed separately from the inpatient claim. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from October 1, 
2021, to October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ketamine. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Medicare-approved drug 
compendia state that the use of ketamine for chronic pain is not useful and should be avoided due to lack of 
long-term safety, efficacy, and timing of repeated ketamine treatments being well established. The services are 
therefore not safe and effective or reasonable and 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 ketamine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36410 billed for date of service April 30, 
2021. 
 
You asked the Plan to pay for procedure code 36410. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 36410 is bundled into payment for code 71275. 
 
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 36410 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. 
 
Additionally, we have confirmed that CPT 76937 is an add-on code that was billed without the appropriate 
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 code 36410 billed for date of service April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gemtesa tablet. 
 
You asked the Plan to pre-approve Gemtesa. 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 Gemtesa 
tablet.  
 Benefits for Gemtesa 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF services provided to the 
enrollee on January 1, 2022. 
 
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 this claim did not require this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly, with a 
valid and supported PDPM code. 
 
This claim required a PDPM code. It was not submitted. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for skilled nursing facility (SNF services provided to the enrollee on January 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 22, 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 procedure codes 63103, 63055, 63056, 63012, 22830, 22852, and 76000 are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 63103 is vertebral corpectomy (vertebral body resection), 
partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in 
addition to code for primary procedure). The definition of code 63055 is transpedicular approach with 
decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; 
thoracic. The definition of code 63056 is transpedicular approach with decompression of spinal cord, equina 
and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral 
extraforaminal approach) (eg, far lateral herniated intervertebral disc). The definition of code 63012 is 
laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina 
and nerve roots for spondylolisthesis, lumbar (Gill type procedure). The definition of code 22830 is exploration 
of spinal fusion. The definition of code 22852 is removal of posterior segmental instrumentation. The definition 
of code 76000 is fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care 
professional time. 
 
We find that CPT codes 63103, 63055, 63056, 63012, 22830, 22852, and 76000 are not supported in the 
medical record. Specifically, there is no documentation of a vertebral corpectomy to support code 63103. There 
is no documentation of a transpedicular approach with decompression of spinal cord, equina, and/or nerve 
roots, single segment, thoracic, to support code 63055. There is no documentation of a transpedicular approach 
with decompression of spinal cord, equina, and/or nerve roots, single segment, lumbar, to support code 63056. 
There is no documentation of laminectomy of removal of abnormal facets and/or pars inter-articularis to 
support code 63012. There is no documentation of exploration of spinal fusion to support code 22830. There is 
no documentation of removal of posterior segmental instrumentation to support code 22830. There is no 
documentation of fluoroscopy to support cod 76000. 
 
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 pay for the surgical services rendered on September 22, 2021.