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

 
We decided that the Plan does not have to pre-approve skilled nursing visits (G0299) for 7 visits per week, and 
home health aide services (G0156) for 2 hours per day 7 days per week. 
 You asked the Plan to pre-approve home health services. You say that you need help with your medications, 
laundry, and other home chores. You say that you are alone and do not have anyone around you. You also say 
that you are sick from your spine and starting to forget everything. 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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that you have documented skilled nursing needs. The reviewer found 
that you do not have documented skilled therapy needs. Therefore, the reviewer found that the requested home 
health skilled nursing services and associated home health aide services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits (G0299) for 7 visits per week, and home health aide services 
(G0156) for 2 hours per day 7 days per week.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 1, 2021. 
 
You asked the Plan to pay for the laboratory 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 26, 2021. 
 
You asked the Plan to pay for the laboratory 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on June 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for leadless pacemaker insertion services provided from 
December 17, 2021, to December 20, 2021. 
 
You asked the Plan to pay for leadless pacemaker insertion services. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says this patient was not in a Medicare-
approved clinical study, so leadless pacemaker insertion is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers leadless pacemakers only when 
performed in the context of an approved clinical study. Leadless pacemakers are non-covered when furnished 
outside of a Medicare-approved study.  This patient was not in an approved clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of leadless pacemaker insertion services have not been met. Therefore, we decided that the Plan does 
not have to pay for leadless pacemaker insertion services provided from December 17, 2021, to December 20, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 15, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig, provided on November 29, 2021. 
 
You asked the Plan to pay for the wig. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the request is not a covered benefit because wigs do not meet the definition of durable 
medical equipment and are cosmetic in nature. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig, provided on 
November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81311, and 81301) provided 
on November 7, 2021. 
 You asked the Plan to pay for the laboratory 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. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81311, and 81301) provided on November 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) and the 
Cerebral perfusion analysis using computed tomography with contrast administration (0042T-26) provided on 
April 5, 2021. 
 
You asked the Plan to pay for codes 70450 and 0042T-26. 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. 
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.  
 
We also find that the PC/TC indicator for code 0042T-26 is "0" = Physician service codes. This indicator 
identifies codes that describe physician services. Examples include visits, consultations, and surgical 
procedures. The concept of PC/TC does not apply since physician services cannot be split into professional and 
technical components. Modifiers 26 & TC cannot be used with these codes. The total Relative Value Units 
(RVUs) include values for physician work, practice expense and malpractice expense. There are some codes 
with no work RVUs. Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of "0" 
indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. In this case, code 0042T-26 
has a modifier indicator of "0." Therefore, we decided that the Plan does not have to pay for the Computed 
tomography (CT) scan (70450) and the Cerebral perfusion analysis using computed tomography with contrast 
administration (0042T-26) provided on April 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says there is no 
documentation of the enrollee receiving or completing anti-tumor treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our physician reviewer 
found that a PET scan is not a standard of care for surveillance of kidney cancer after ablative therapy. Per the 
National Comprehensive Cancer Network (NCCN) Guidelines abdominal computed tomography or magnetic 
resonance imaging (CT or MRI) with and without IV contrast at 16 months following ablative therapy unless 
otherwise contraindicated, then CT or MRI (preferred), or ultrasound annually for 5 y or longer as clinically 
indicated. If the enrollee is unable to receive intravenous contrast, MRI is the preferred imaging. Therefore, the 
service is 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Neulasta (J2506). 
 
You asked the Plan to pre-approve Neulasta. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Neulasta. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Zarxio, Ziextenzo, and pegfilgrastim biosimilars before they will approve the 
requested drug. The enrollee has not tried and failed the required drugs. The Plans required drugs would not 
likely be less effective and/or 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 Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Neulasta (J2506).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment for these services. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed for date of service June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2199), purchased on October 1, 2021. 
 
You asked the Plan to pay for the progressive lens. You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item.  
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. The Plan covers these services when Standard lenses that are covered in full include standard single 
vision, lined bifocal, lined trifocal, lenticular, and standard progressive lenses when purchased through the 
Plan's vision providers. 
 
We looked at the file and the Plan's rules. Progressive lenses are not covered when obtained out-of-network. 
Based on this information, we decided that the Plan's rules for coverage of the progressive lens have not been 
met. Therefore, we decided that the Plan does not have to pay for the progressive lens (V2199), purchased on 
October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies and materials by a physician rendered on 
September 10, 2021 to 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 the services 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99070 is not separately payable. 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 supplies 
and materials by a physician rendered on September 10, 2021 to October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye exam (92014) provided on 
December 8, 2021. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that this was an annual routine eye 
exam, and you should only have a $15 copayment. The Plan denied your request. The Plan says this claim was 
processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $40 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.  
 
You have been asked to pay a $40 copayment for the eye exam. The medical records in this case show that this 
eye exam was provided as a follow up for previous medical vision complaints. Medical diagnoses were 
submitted with this claim. A routine eye exam is one that is only provided to detect changes in vision for the 
purpose of eyeglasses or contacts. The eye exam in this case falls within the each Medicare-covered outpatient 
visit for services to diagnose and/or treat a disease or condition of the eye 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 reduce the copayment for the eye exam (92014) provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Sanexas neoGen- Series Therapy (electrical cell 
stimulation), Vasopneumatic device therapy (97016), the associated codes for the subcutaneous injection of 
FDA Nutri-Pharmaceutical blend, and all other associated codes including 96372, completed by a non-PAR 
provider on service dates October 7, 2020, through June 7, 2021. 
 
You asked the Plan to pay for Vasopneumatic device therapy and associated codes for the subcutaneous 
injection of FDA Nutri- Pharmaceutical blend. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is experimental.  
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 pay for Vasopneumatic device therapy and 
associated codes for the subcutaneous injection of FDA Nutri- Pharmaceutical blend. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the services are experimental and unproven to provide benefit for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vasopneumatic device therapy and associated codes for the subcutaneous 
injection of FDA Nutri- Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not 
have to pay for  the Sanexas neoGen- Series Therapy (electrical cell stimulation), Vasopneumatic device 
therapy (97016), the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend, and 
all other associated codes including 96372, completed by a non-PAR provider on service dates October 7, 
2020, through June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
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 a repeat epidural steroid injection. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested service does not meet the criteria of sustained pain relief of 50% 
for 3 months or a change in approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (62323).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of aorta (93978) provided on November 23, 
2021. 
 
You asked the Plan to pay for the duplex scan. You say that these services were billed correctly and should be 
paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 93975 and 93978. This PTP edit has a modifier indicator of 0, meaning 
modifiers associated with NCCI are not allowed to bypass this edit. These codes cannot be billed together. 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 93978 
is a column II code to column I code 93975. This code pair does not allow a modifier to bypass the edit. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for the duplex scan of aorta (93978) provided on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MTHFR genetic testing provided on November 17, 2021. 
 
You asked the Plan to pay for the MTHFR genetic 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. 
 
The Plan must follow Medicare rules. The rules say that MTHFR genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The services at issue are MTHFR genetic testing. This testing is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the MTHFR genetic testing 
provided on November 17, 2021.