Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If this enrollee has chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does 
not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that 
can be provided with BiPAP.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary and this claim should be reconsidered. 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 January 7, 2022, to 
February 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4215 billed for date of service September 
8, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the service is not 
covered. 
 
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 A4215 is not in the statutory definition of "physician services" for fee schedule 
payment purposes. No payment amounts are shown for these codes, and no payment may be made under the 
physician fee schedule. 
 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code A4215 billed for date of 
service September 8, 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 enrollee's post short term acute 
hospital stay will be best managed at LTACH, and medical needs are too complex for skilled nursing facility. 
The Plan denied your request. The Plan says the enrollee is receiving the care needed in the current hospital 
and there is no need to transfer to the LTACH until safe for transfer or discharge. 
 
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 there is no evidence that the enrollee requires services that are not currently available 
and can then be transferred/discharged to a lower level of care for any ongoing needs. 
 
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: 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 enrollee is stable and has strong 
criteria for LTACH admission, needs transition to that level of care for pulmonary and medical management as 
well as stating an aggressive rehabilitation program. The Plan denied your request. The Plan says the enrollee 
does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no 
issues for which LTACH may offer a therapeutic advantage. 
 
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 enrollee continues to require care at an acute hospital and can receive further care 
at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the modifier is valid and payable. The Plan denied 
your request. The Plan says the documentation does not support the billed charges. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We looked at the file and the rules. The medical records provided do not show that procedure codes 88368, 
88369, 88377, and G0452, billed with the -59 modifier, were distinct procedural services. Modifiers should not 
be used just to bypass an edit. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87798, 
87150, 87481m 87500m 87640, 87801, 87651 and 87653) provided on May 10, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this test was medically necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says this panel was not 
billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a urine PCR panel have not been met. Specifically, the records show that a single panel was 
ordered and performed, but this service was billed by reporting individual components. Therefore, we decided 
that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87798, 87150, 87481m 
87500m 87640, 87801, 87651 and 87653) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genium microprocessor knee. 
 
You asked the Plan to pre-approve a Genium microprocessor knee. 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 follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Genium microprocessor knee. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the Genium X3 microprocessor knee at issue in this case meets 
all of Medicare's LCD criteria for medically reasonable and necessary for you. Provided medical records from 
your provider in this case do not support that you are a K4 level ambulator as noted by the vendor/prosthetist; 
the medical provider does not designate your ambulatory level in the provided face to face visit note. Provided 
medical records from your provider in this case do not explain why a K3 mechanical knee would not meet your 
mobility needs or why you require the waterproof features of the X3 knee in your occupation as a psychologist. 
Records do not show trial and failure of a K3 mechanical knee or why the Genium X3 knee is the only 
prosthetic knee that will meet your needs. 
 
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 Genium microprocessor knee have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Genium microprocessor knee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on September 16, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visit 
provided on September 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate. 
 
You asked the Plan to pre-approve Nplate. 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 anti-cancer 
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 Nplate. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested drug is not FDA-approved 
for the enrollees diagnosis. The use 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 Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nplate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 15, 2022, billed with 
codes 81455, 81301 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 15, 2022, billed with codes 81455, 81301 and 81194.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adapter plate and foot plate bracket assembly both 
described by code K0108. 
 
You asked the Plan to pre-approve the adapter plate and foot plate bracket assembly. You say that the requested 
items should be approved. The Plan denied your request. The Plan says these two items requested under code 
K0108 are not correctly coded. 
 
The Plan must follow Medicare rules. Medicare rules say that K0108 may be used to describe components of a 
wheelchair that do not have a specific assigned code. In addition, it is noted that codes for wheelchair seating 
are all -inclusive and no components may be billed separately using K0108. 
 
We looked at the file and Medicare rules. K0108 for the foot plate assembly is not appropriate as there are 
specific codes for foot plates. Since the adapter plate is needed for use of the seating, this cannot be reported separately from the codes for the seating. Based on this information, we decided that Medicare rules for 
coverage of the adapter plate and foot plate bracket assembly have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an adapter plate and foot plate bracket assembly both described by code 
K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4215 billed for date of service September 
1, 2022. 
 
You asked the Plan to pay for procedure code A4215. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4215 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4215 is statutorily excluded from Medicare payment. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4215 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4215 billed for date of service September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code A4556. The Plan denied your request. The Plan says procedure 
code A4556 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4556 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4556 is not separately payable. 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 procedure code 
A4556 billed for date of service April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for November 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99213 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99213 was billed on the same day and related to 
minor surgical procedure 64490. The -25 modifier is not supported as a separate service from the procedure. 
Payment for code 99213 is included in the global surgical package for code 64490. Therefore, we decided that 
the Plan does not have to pay for procedure code 99213 billed for November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the specialist visit, and the 
methylprednisolone acetate injection provided by an in-network provider on November 5, 2021. 
 
You asked the Plan to waive the cost sharing for the specialist visit and the injection. You say that you think 
that the enrollee is being balance billed. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $35 copayment for in-network services obtained from a specialist, or under certain circumstances, 
treatment by a nurse practitioner or physicians assistant or other non-physician health care professionals in a 
specialists office, and a 20% coinsurance for each in-network Medicare-covered Part B drug. The enrollee has been asked to pay a $35 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. The enrollee has also been 
asked to pay a $1.11 coinsurance for the injection ($5.55 allowed amount x .20 = $1.11). This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost sharing for the specialist visit, and the methylprednisolone acetate injection provided by an in-network 
provider on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), extraction, erupted 
tooth or exposed root (elevation and/or forceps removal) (D7140), inhalation of nitrous oxide/analgesia, 
anxiolysis (D9230), and consultation - diagnostic service provided by dentist or physician other than requesting 
dentist or physician (D9310) provided on July 21, 2022 and September 28, 2022. 
 
 You asked the Plan to pay for codes D7210, D7140 D9230, and D9310. You say that the enrollee needed the 
extractions due to a heart condition. The Plan denied your request. The Plan says these services are not covered 
under the benefit package. 
 
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. Since the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) 
was performed with the non-covered services this benefit denied as it was not partnered with a covered 
procedure. Therefore, we decided that the Plan does not have to pay for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 
(D7210), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230), and consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on July 21, 2022 and September 28, 
2022.