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

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service August 
28, 2022. 
 
You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
August 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided August 1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that it is impossible for the enrollee to 
initiate and continue treatment without the prescribed supplies A4595, as the devices design function for 
treatment require said supplies for regimen. The Plan denied your request. The Plan says evidence of 
misrepresentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider 
office and verified that the provider did not order the DME item. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) (A4595) provided 
August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental office visit (99205) 
 
You asked the Plan to pre-approve the dental office visit. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental office visit (99205)
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
provided to the enrollee on August 24, 2022. 
 
You asked the Plan to pay for the services. You say that the denial is inconsistent with Federal law. The Plan 
denied your request. The Plan says CPT 99283 is more appropriate than CPT 99284. 
 
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 CPT 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function." 
 
We asked our coder 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 supported by the medical records. Our reviewer found that the review indicates that CPT 
99284 was not substantiated by the clinical documentation. The enrollee was stable with normal vital signs and 
no laboratory work ordered. There was no sign of multiple system dysfunction or a need for specialty 
consultation. The presentation was not one of high severity requiring urgent evaluation and no acute situation 
of a complex nature to support the level of care billed. The review has determined that the presenting problems 
were not of high severity, requiring urgent evaluation. The presenting problems were not posing an immediate 
significant threat to life or physiologic function. 
 
We looked at this coder'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 emergency department services (procedure code 99284) provided to the enrollee on August 24, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron HCL. 
 
You asked the Plan to pre-approve Palonosetron HCL. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Palonosetron HCL. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found Palonosetron HCL is Food and 
Drug Administration-approved for the prophylaxis of chemotherapy-induced nausea and vomiting associated 
with moderately or highly emetogenic cancer chemotherapy. Provided records do not document that this 
enrollee is receiving moderately or highly emetogenic cancer chemotherapy as defined by the American 
Society of Clinical Oncology's "Antiemetics in Oncology: Clinical Practice Guideline." The use of 
Palonosetron HCL to treat nausea associated with myasthenia gravis on treatment with Soliris is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron HCL have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Palonosetron HCL.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 17, 2022 to 
April 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you were not aware of the 
change to NOAs, so this claim should be reprocessed. The Plan denied your request. The Plan says the claim 
has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 17, 2022 to April 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the home gym equipment purchased on  
July 14, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We reviewed the case file and the Plans rules. Based upon this information, we decided that the Plans rules 
for coverage of this item has not been met. Specifically, the Plan does not provide coverage for gym equipment 
under the wellness benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the 
home gym equipment purchased on July 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the care the enrollee needs can be received in an alternate level of care. 
 
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 that the enrollee does not require the intensity of services provided at an IRF. The 
enrollee's care needs can be met a lower 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided all documents needed to have 
this claim processed. 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, for 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 provided on June 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. It appears that you billed one unit with the LT modifier and one unit with the RT 
modifier instead of one unit with the bilateral modifier as is required. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76641 billed for date of service October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99221-57 billed for date of service September 2, 2022. 
 
You asked the Plan to pay for code 99221-57. You say that this service was medically necessary and should be 
separately paid. The Plan denied your request. The Plan says this code is not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that Medicare does not pay 
for an E/M service billed with 57 if it was provided on the day of, or the day before, a procedure with a 000- or 
010-day global surgical period.  In this case, the surgical procedure performed (code 21320) is considered a 
minor surgery with a 000-day global surgical period. However, you billed the E/M service in dispute with a 57 
modifier, which is not permissible for services related to a minor surgery.  The 57 modifier only allows for 
separate payment of the E/M service if it is related to a major surgery. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99221-57 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99221-57 billed for date of service September 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 23, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 October 23, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ramucirumab (J9308) provided on October 19, 2021. 
 
You asked the Plan to pay for the Ramucirumab. You say that you do not deem this drug to be experimental. 
The Plan denied your request. The Plan says experimental or investigational services are not covered. 
 
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 the Ramucirumab. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not sufficiently support that the Ramucirumab (J9308) is medically 
reasonable and necessary for the patient as there was no Food and Drug Administration (FDA) approved 
indication (colon cancer, lung cancer, esophageal cancer, gastric cancer, or liver cancer) mentioned in the 
provided documentation. Our reviewer also found that the documentation, does not support that the 
Ramucirumab (J9308) is safe and effective for the enrollee without evidence of a clear clinical FDA-approved 
indication.  
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 Ramucirumab have not been met. Therefore, we decided that the Plan does 
not have to pay for the Ramucirumab (J9308) provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code E0675-RR provided on April 14, 2022. 
 
You asked the Plan to pay for procedure code E0675-RR. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. Medicare rules say claims must specify whether equipment is rented or 
purchased. In this case, the claim was billed with the appropriate RR modifier to indicate that the device was 
rented. The Plan provided no evidence that the device was not rented. The Plan has not made any other 
argument besides the RR modifier being inappropriate. We find that the denial of payment has not been 
substantiated. Therefore, we decided that the Plan has to pay for procedure code E0675-RR provided on April 
14, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve home health services. You say that you have a letter of agreement from the 
health Plan and have the letter to provide proof that they are able to see the member. The Plan denied your 
request. The Plan says the member's Plan has a lock-in feature. This member has been approved for home 
health visits with an RN who is skilled in tracheostomy care. This is an appeal for an out-of-network provider 
for home health visits. Under the Evidence of Coverage, covered out-of-network services are those received for 
any of the following: emergency services, unforeseen out-of-geographic-service-area urgently needed services, 
routine travel dialysis, or services the Plan has prior-authorized. The principal reason for prior authorization for 
out-of-network care is for medically necessary services when those services cannot be obtained in network. If 
none of these circumstances apply, neither the health Plan nor Medicare covers out-of-network services.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that this drug is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 Myrbetriq.  
 Benefits for Myrbetriq 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan and Low osmolar contrast material (71260, 
Q9967) provided on August 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan and Low osmolar contrast material. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
  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 a CT scan and Low osmolar contrast material 
(71260, Q9967) provided on August 26, 2022, by an out-of-network (OON) provider.