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

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2022. 
 
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, 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 August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. 
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product (0628T). 
 
You asked the Plan to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product. 
You say that the service is medically necessary. The Plan denied your request. The Plan says the requested 
percutaneous injection of allogeneic cellular and/or tissue-based product is unproven and has insufficient 
evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a percutaneous injection of allogeneic 
cellular and/or tissue-based product. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the literature indicates that to date, 
injections of mesenchymal stem cells are unproven and not medically necessary for enhancement of healing as 
evidence is lacking. Degenerative discs lack blood supply to support viability of living tissues. There is poor 
likelihood of survivability of injected materials.  
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 percutaneous injection of allogeneic cellular and/or tissue-based product have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous injection of 
allogeneic cellular and/or tissue-based product (0628T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half 
leg (E0673), provided on April 29, 2022. 
 
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance. You say that the item 
should be covered. The Plan denied your request. The Plan says this item is not covered for this place of 
service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the segmental gradient pressure pneumatic appliance was used in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic 
appliance, half leg (E0673), provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (CPT code 99334) provided on August 18, 2022. 
 
You asked the Plan to pay for the out-of-network service. You say that the assisted living facility is responsible 
to obtain prior authorization for all of their patients, which should also cover for the medical treatments 
provided. The Plan denied your request. The Plan says this provider is out-of-network, the services were not 
referred by a network provider, and the services were not urgent or emergent, nor were they approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the 
evaluation and management of an established patient (CPT code 99334) provided on August 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on June 28, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private care, 
taxi) without endangering the enrollee's condition. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 16, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee 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 August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3310) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for endodontic therapy (D3310) provided on August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 4, 2022, billed with 
codes 87632, 87633, 0115U, 0202U, 0223U, and 0225. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
March 4, 2022, billed with codes 87632, 87633, 0115U, 0202U, 0223U, and 0225.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (44146) provided on June 11, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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 44146 is Colectomy, partial; with coloproctostomy (low 
pelvic anastomosis) with colostomy. 
 
We find that CPT code 44146 is not supported in the medical record. Specifically, the operative report does not 
describe low pelvic anastomosis, and in this case there is a more appropriate code to report. Based on this 
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, 
we decided that the Plan does not have to pay for surgical services (44146) provided on June 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for the dental 
services on June 27, 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 the inpatient rehabilitation is medically necessary 
and will be beneficial. The Plan denied your request. The Plan says you don't meet the conditions for a stay in 
an inpatient rehabilitation facility. 
 
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 you are medically stable and do not need physical medicine 
and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management 
of any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs are 
identified or documented. You have no medical acuity and not acute rehabilitation nursing needs for IRF 
admission. While you would benefit from physical therapy and occupational therapy, your rehabilitation needs 
can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted procedure, larynx (micro direct Wendler 
glottoplasty) (31599). 
 
You asked the Plan to pre-approve the micro direct Wendler glottoplasty. You say that the enrollee is a 
candidate for gender affirming voice surgery. The enrollee has taken all required steps to move forward with 
Wendler glottoplasty The Plan denied your request. The Plan says the request for the micro direct (Wendler) 
glottoplasty does not meet the criteria for medical necessity. 
 
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 micro direct Wendler glottoplasty. 
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 support that Wendler glottoplasty is 
reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a 
malformed body member. There is insufficient long-term evidence supporting Wendler glottoplasty. 
 
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 micro direct Wendler glottoplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the unlisted procedure, larynx (micro direct Wendler glottoplasty) 
(31599).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a member qualifies for a powered pressure-
reducing air mattress when the criteria listed in the Medicare Rules section is met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 1, 2022, to May 14, 
2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says a NOA was not submitted. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
Review of the file shows that an NOA was not submitted for the services rendered. As an NOA is required, no 
payment can be made on this claim without one. Therefore, we decided that the Plan does not have to pay for 
the home health services provided May 1, 2022, to May 14, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the intravenous infusion or subcutaneous injection 
(M0243) provided on January 21, 2022. 
 
You asked the Plan to pay for the intravenous infusion or subcutaneous injection. You say that you would like 
this claim to be processed and paid because as far as you know, Medicare covers all COVID-19 related 
procedures. The Plan denied your request. The Plan says that this procedure is not covered by the Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the intravenous infusion or subcutaneous injection by a contract provider. The file does 
not show that the Plan provided notice that the intravenous infusion or subcutaneous injection would not be 
covered. Under Medicare rules, this means the intravenous infusion or subcutaneous injection is considered 
approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the intravenous infusion 
or subcutaneous injection (M0243) provided on January 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on June 6, 
2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the claim should be paid. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on June 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 25, 
2022 to August 4, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says clinically, the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from July 25, 2022 to August 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve Trivisc. You say that you are going through a lot of pain and you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested drug 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 pre-approve Trivisc. Our reviewer says that the 
documentation does not support that Our physician reviewer found you have a diagnosis of knee pain for one 
month duration.  The record does not indicate that you have tried and failed conservative nonpharmacologic 
therapy or to simple analgesics, such as acetaminophen. The record provided does not include primary source 
results of knee radiographs documenting osteoarthritis. Therefore, you do not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.