Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on January 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that an authorization should be on file, 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 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided to the enrollee 
on February 3, 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 billed with the wrong place of service. 
 
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 99336 is "Domiciliary or rest home visit for the 
evaluation and management of an established patient, which requires at least 2 of these 3 key components: A 
detailed interval history; A detailed examination; 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 moderate to high severity. Typically, 40 minutes are spent with the 
patient and/or family or caregiver." 
 
We find that CPT code 99336 is not supported in the medical record. Specifically, a place of service of "office" 
(11) would not be appropriate for this service, as it is for a domiciliary or rest home visit. 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 evaluation and management services provided to the enrollee on 
February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve Ubrelvy. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
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 Ubrelvy.  
 
Benefits for Ubrelvy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim to be 
reconsidered for payment for medical necessity, as pneumatic compression devices are a proven treatment for 
deep venous thrombosis. The Plan denied your request. The Plan says services not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Prolia injection (J0897). 
 
You asked the Plan to pay for Prolia. You say that the Prolia injection was medically necessary. The Plan 
denied your request. The Plan says that the Prolia injection is 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 pay for Prolia. Our reviewer says that the Prolia 
injection was medically necessary. Our physician reviewer found the provided documentation indicates that the 
Prolia injection is medically reasonable and necessary for the patient. The documentation also supports that the 
Prolia is safe and effective for the enrollee. Therefore, the reviewer found that the Prolia injection was 
medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pay for Prolia 
injection (J0897).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided July 28, 
2021 to August 24, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema/inflammation and post-surgical lymphedema. You believe these services were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided July 28, 2021 to August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to an inpatient psychiatric hospital on June 9, 2022. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested inpatient psychiatric hospital care is medically reasonable and necessary. 
Our physician reviewer found that the enrollee is a 54-year-old male who was involuntarily admitted to the 
acute inpatient psychiatric hospitalization on June 9, 2022, with Schizoaffective Disorder Bipolar Type. Based 
upon review the records provided it was expected this enrollee would improve in a reasonable period of time. 
Furthermore, he did not have dangerousness to self; however, he did have dangerousness to others. He did not 
have any auditory or visual hallucinations but was showing any behavioral issues. In this case, it did appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care as although he did not have dangerousness to self, he did toward others with bizarre 
behaviors and anger toward his neighbors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve admission to an inpatient psychiatric hospital on June 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CGM and supplies (CPT code(s): K0553 and K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies is necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation shows that you do not need insulin at least three 
(3) times a day and you do not need to adjust your insulin frequently. Based on this information, we decided 
that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CGM and supplies (CPT code(s): K0553 and K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular disease screening test provided to the 
enrollee on August 5, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 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 testing. Our reviewer says that the requested services are 
not medically reasonable or necessary. Our reviewer found only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). The review has determined that the services at issue in this case are not medically 
reasonable or necessary. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a cardiovascular disease screening test provided to the enrollee on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular Peripheral Nerve Stimulation (PNS) device. 
 
You asked the Plan to pre-approve an auricular PNS device. 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. Medicare rules say that acupuncture for stimulation of auricular points is 
not a covered Medicare benefit.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an auricular PNS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an auricular Peripheral Nerve Stimulation (PNS) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, material, and clinical staff time over and 
above those usually included in an office visit or other non-facility services when performed during a Public 
Health Emergency (code 99072) and medical supplies (codes A4253, A4556, and A4557) provided on 
February 18, 2021. 
 You asked the Plan to pay for Public Health Emergency expenses and supplies. You say that your provider was 
asked to participate in this procedure. The Plan denied your request. The Plan says the denial of payment for 
these services and items is correct, because code 99072 has a Status Code of B and codes A4253, A4556, and 
A4557 have a Status Code of P indicating that these codes are bundled for payment and 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 99072 has a status indicator of B on the Physician Fee Schedule. Codes A4253, A4556, 
and A4557 have a Status Code of N. This means that CPT codes 99072, A4253, A4556, and A4557 are not 
separately payable. Based on this information, we decided that Medicare rules for coverage of Public Health 
Emergency expenses and supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for additional supplies, material, and clinical staff time over and above those usually included in an office visit 
or other non-facility services when performed during a Public Health Emergency (code 99072) and medical 
supplies (codes A4253, A4556, and A4557) provided on February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 21, 
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 an appropriate modifier was not billed with this code edit. 
 
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 imaging services provided to the enrollee on January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 You asked the Plan to pre-approve additional routine transportation mileage. You say that you are asking for an 
additional 68 miles for a total of 143 miles. The Plan denied your request. The Plan says the requested amount 
exceeds the limit listed by the plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
Review of the file shows that your request for an additional 68 miles for a total of 143 miles exceeds your 
benefit. Your 2022 EOC states each one-way trip must not exceed 75 miles of driving distance. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on June 2, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the services were rendered 
based on the patient's condition and was essential to their quality of health. You say that the procedures codes 
and modifier were applied appropriately. The Plan denied your request. The Plan says procedure code 01916 
has been overturned and procedure code 99100 remains denied as bundled services are not eligible for separate 
reimbursement. 
 
  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest X-ray (71045) provided on January 12, 2022. 
 
You asked the Plan to pay for a chest X-ray. You say that you have provided medical records to support the 
service at issue. The Plan denied your request. The Plan says rules for payment have not been met because the 
service at issue is inclusive to another billed code. 
 
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 71045 
is a column II code to column I code 36558. 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 a chest X-ray (71045) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full-mouth/complete x-ray set for evaluation of the teeth 
and mouth (CPT code D0210). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says you exhausted your benefit frequency limit. 
 
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. Review of the file shows full-
mouth/complete x-ray set for evaluation of the teeth and mouth were rendered on January 24, 2022. Your 2022 
EOC states Full-mouth/Complete x-ray set for evaluation of the teeth and mouth - D0210: One (1) procedure 
every three (3) plan years. Therefore, you exhausted your benefit frequency limit. Therefore, we decided that 
the Plan does not have to pre-approve full-mouth/complete x-ray set for evaluation of the teeth and mouth 
(CPT code D0210).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on February 4, 2022. 
 
You asked the Plan to pay for the services provided. You say that the documentation provides evidence of 
medical necessity. The Plan denied your request. The Plan says the claim was billed with an inappropriate 
place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 In this case, CPT code 85060 was billed with an outpatient place of service (22). No payment is recognized for 
code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the pathology services provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99202) provided on 
January 25, 2022, by a chiropractic provider. 
 
You asked the Plan to pay for an office visit. You say that the service at issue was an appointment with a 
specialist to establish you as a new patient and should be covered. The Plan denied your request. The Plan says 
the service at issue is not a covered benefit when billed by a chiropractic provider. 
 
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 an office or other outpatient visit (99202) provided on January 25, 2022, by a 
chiropractic provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on November 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results are necessary in choosing the most 
appropriate course of treatment for this enrollee. The Plan denied your request. The Plan says the testing is not 
a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file, and Medicare rules. The FoundationOne genomic profiling test includes the FANCC 
gene. Panels of test that includes this gene is statutorily excluded. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the gene panel provided on November 10, 2021.