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

 
We decided that the Plan does not have to pay for a home health visit provided on January 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 home health visit provided on January 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system (E1399). 
 
You asked the Plan to pre-approve a life alert system. You say that the services should be covered because the 
enrollee has had multiple falls. The Plan denied your request. The Plan says this would be considered a 
convenience item primarily hygienic in nature or a device that is not primarily medical in nature and thus not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a life alert system (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (15736 and 15100) provided on June 18, 
2021. 
 
You asked the Plan to pay for codes 15736 and 15100. You say that the medical records support the billing of 
codes 15736 and 15100 provided on June 18, 2021. The Plan denied your request. The Plan says the medical 
records do not support the billing of codes 15736 and 15100 provided on June 18, 2021. 
 
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 15736 is Muscle, myocutaneous, or fasciocutaneous flap; 
upper extremity. The definition of code 15100 is Split-thickness autograft, trunk, arms, legs; first 100 sq cm or 
less, or 1% of body area of infants and children (except 15050). 
 
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 codes 15736 and 15100. Our reviewer says that the medical records do not support the billing of codes 15736 and 15100 provided on June 18, 2021. Our reviewer found 
per CPT, reporting of a muscle, myocutaneous, or fasciocutaneous flap is always identified by the donor site, 
never by the recipient site. In 15734-15378, the physician repairs a defect area using a muscle, muscle and skin, 
or a fasciocutaneous. The physician rotates the prepared flap from the donor area to the site needing repair, 
suturing the flap in place. The donor area is closed primarily with sutures. As such, reporting of CPT code 
15734-15378 requires that the muscle is mobilized, elevated, isolated on its primary or secondary blood supply 
and then transferred locally or regionally. The operative report does not support this and therefore, code 15736 
cannot be verified. 
 
Procedure code 15100 is not supported by the medical records submitted. The operative report did not include 
documentation of a split-thickness autograft of the trunk, arms and legs; for the first 100sq cm or less (except 
15050); therefore, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 15736 and 15100 have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (15736 and 15100) provided on June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (63081 and 20937) provided on July 27, 
2021. 
 
You asked the Plan to pay for codes 63081 and 20937. You say that the medical records support the billing of 
codes 63081 and 20937 provided on July 27, 2021. The Plan denied your request. The Plan says the medical 
records do not support the billing of codes 63081 and 20937 provided on July 27, 2021. 
 
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 63081 is Vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment. The definition of code 20937 is Autograft for spine surgery only (includes harvesting 
the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary 
procedure). 
 
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 codes 63081 and 20937. Our reviewer says that the medical records do not support the billing of codes 63081 and 20937 provided on 
July 27, 2021. Our reviewer found both codes are not supported by the operative note. There is no 
documentation of partial corpectomy removing at least 1/2 of the vertebral body. There is no documentation of 
bone graft through a separate incision. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 63081 and 20937 have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (63081 and 20937) provided on July 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility care. 
 
You asked the Plan to pre-approve skilled nursing facility care. You say that you require skilled nursing facility 
care. The Plan denied your request. The Plan says The member does not meet Medicare Criteria found in the Medicare Benefit Policy Manual, Chapter 8, Section 30, as the member does not require the daily skilled 
therapy or nursing services required to qualify for a skilled nursing facility stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 skilled nursing facility care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found Based on the 
documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage.  The enrollee 
does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy 
needs.  Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition.  The enrollees care needs, as a practical matter, be provided at a 
lower level of care (ex. LTC). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing facility care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand-finger orthosis (L3924) with sales tax (S9999) 
provided by an online retailer on February 24, 2022. 
 
You asked the Plan to pay for a hand-finger orthosis. You say that the item at issue was a medical necessity for 
you. The Plan denied your request. The Plan says rules for payment have not been met because the provider at 
issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a hand-finger orthosis (L3924) with 
sales tax (S9999) provided by an online retailer on February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member is ready to transfer. The Plan 
denied your request. The Plan says based on Medicare guidelines, the LTACH services requested do not meet 
the requirements for approval. 
 
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 the patient appears to be stable and improving and requires only short term additional 
acute care hospital services that can be safely administered at the current facility until more appropriate for a 
lower level of care. Our physician reviewer also found that a transfer to LTACH is not medically necessary as 
it would not be clinically advantageous at this time, and 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a medical 
necessity for you The Plan denied your request. The Plan says medical necessity rules for coverage of the 
requested item have not been met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that you are unable to lift the portable tanks that have been provided but have also refused 
delivery of lighter portable tanks. The available medical records do not include ambulatory oximetry to 
demonstrate that oxygen saturation can be maintained 91% or greater with an oxygen conserving device and 
flow 1 - 4 L/min. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 18, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
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 an office visit provided on January 18, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (22845) provided January 11, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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 22845 
has a bundled relationship with code 22853. 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 surgical services (22845) provided January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elbow viscosupplementation injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says viscosupplementation of joints other than the knee(s) are considered not reasonable and 
necessary and are not subject to coverage. 
 
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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an off-label use of this injection. Medicare specifically excludes the use of viscosupplements in 
joints other than the knees. therefore, the request was not medically reasonable or necessary. 
 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an elbow viscosupplementation injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99241) injection, dexamethasone 
sodium phosphate, (J1100) injection, triamcinolone acetonide, not otherwise specified (J3301) injection, 
vitamin B12 cyanocobalamin (J3420) provided January 27, 2022. 
 
You asked the Plan to pay for the office visit. You say that you paid up front for the services and you want the 
Plan to pay you back. The Plan denied your request. The Plan says if you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99241) injection, dexamethasone sodium phosphate, (J1100) injection, triamcinolone 
acetonide, not otherwise specified (J3301) injection, vitamin B12 cyanocobalamin (J3420) provided January 
27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on August 16, 2021.
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 (64625 x 1). 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that RFA to the SI joint is medically necessary. 
The Plan denied your request. The Plan says RFA to the SI joint is not medically necessary and does not meet 
the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say surgically induced lesions of nerve tracts which involve 
destruction of nerve tissue are primarily indicated for controlling the chronic or acute pain arising from 
conditions such as terminal cancer or lumbar degenerative arthritis.  
 
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 to the SI joint. Our reviewer says 
that RFA to the SI joint is not medically necessary. Our physician reviewer found The requested RFA SI joint 
under imaging guidance (64625) has not been proven effective and is considered experimental/ investigational. 
The review has determined that the requested SI joint RFA is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA to the 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 (64625 x 1).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on February 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility requested your services and the 
service rendered to the enrollee was medically necessary. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 home health visit provided on February 10, 
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 the spinal imaging and electrical stimulation provided on 
January 25, 2022. 
 
You asked the Plan to pay for the chiropractor services. You say that you need these services covered because 
they are able to help your condition when other treatments have not. The Plan denied your request. The Plan 
says these services cannot be covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the spinal imaging and electrical stimulation provided on January 25, 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 February 12, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. 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 February 12, 
2022.