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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on December 16, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that reconsideration should be made for the 
recoupment of payment. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on December 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy, flexible, transoral; with 
biopsy, single or multiple (43239) provided on June 24, 2021. 
 
You asked the Plan to pay for the surgical service. You say that no hospice coverage existed for the enrollee on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 20, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided on June 24, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral open sacral iliac joint fusion procedure 
represented by CPT 27280. 
 
You asked the Plan to pre-approve bilateral open sacral iliac joint fusion procedure. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 bilateral open sacral iliac joint fusion 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for pseudoarthrosis after 
fusion or arthrodesis. Detailed documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures directed to the bilateral sacroiliac joints, including 
injections. The provided diagnostic imaging studies did not demonstrate sacroiliac pathology, bilaterally. 
Additionally, the rationale is not evident as to why an open procedure is being requested over minimally 
invasive procedure or percutaneous procedure. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral open sacral iliac joint fusion procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve bilateral open sacral iliac joint fusion procedure 
represented by CPT 27280.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for direct skilled nursing services, home health services, 
occupational therapy and physical therapy provided on February 1, 2022, to February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for direct skilled nursing services, home health services, occupational therapy and 
physical therapy. You say that authorization is not required for home health services. The Plan denied your 
request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 direct skilled nursing services, home health 
services, occupational therapy and physical therapy provided on February 1, 2022, to February 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (99217) billed 
on January 3, 2022. 
 
You asked the Plan to pay for observation care discharge day management (99217). You say that CPT code 
99217 was only billed once and was coded correctly. You say that the documents support CPT code 99217, and 
the code should be reconsidered for payment. The Plan denied your request. The Plan says a qualifying initial 
or subsequent observation care service has not been reported. 
  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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, there is no evidence that an 
initial or subsequent observation service has been billed. Based on this information, we decided that Medicare 
rules for coverage of observation care discharge day management (99217) have not been met. Therefore, we 
decided that the Plan does not have to pay for observation care discharge day management (99217) billed on 
January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on January 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43247) provided on 
November 9, 2020. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. The Plan denied your request. The Plan says 
this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the esophagogastroduodenoscopy 
(43247) provided on November 9, 2020 have been met. Medical records were not provided for this case. The 
Plan asked for medical records multiple times, but they were not provided. Without this information we cannot 
determine that the service provided was medically necessary. Therefore, we decided that the Plan does not have 
to pay for the esophagogastroduodenoscopy (43247) provided on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 12, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service February 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed on February 9, 2022. 
 
You asked the Plan to pay for procedure code 69990. You say that medical records are attached, and the claim 
should be processed for payment. The Plan denied your request. The Plan says there are no modifiers allowed 
with this code pair. 
  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 69990 
is a column II code to column I code 63030 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 69990 billed on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick external catheters. 
 
You asked the Plan to pre-approve Purewick external catheters. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
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 Purewick external catheters. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of urinary incontinence. There are no peer-
reviewed articles published in the medical literature specific to the PureWick system, or external urinary 
collection system using a continuous low-pressure pump. There is no evidence to show the PureWick system to 
be an effective alternative in managing urinary incontinence. Therefore, the enrollee does not meet criteria for 
the requested items. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Purewick external catheters have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Purewick external catheters.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 13, 2022, to March 14, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from February 13, 2022, to 
March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 20, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says prior approval was not obtained for these services rendered. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that other means of transport (such as stretcher van) were contraindicated for 
this patient.  The documentation does not support that the patient needed the expertise, services and lifesaving 
and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The records 
state that the patient was weak and was not able to be transported via wheelchair safely. No treatment was 
received during transport and vitals were stable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker (E0143, E0156). 
 
You asked the Plan to pre-approve the walker. You say that the walker is medically necessary. The Plan denied 
your request. The Plan says a walker has already been provided and a 3 wheel scooter was approved. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker. The walker already provided serves the same purpose as the requested 
walker. Therefore, we decided that the Plan does not have to pre-approve a walker (E0143, E0156).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for cataract surgery. 
 
You asked the Plan to pre-approve the referral. You say that you had an appointment at the ophthalmology 
department and waited there for an hour and was never seen. The Plan denied your request. The Plan says a 
referral out-of-plan is not indicated. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for cataract surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's decision. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has a history of an 
osteoporotic fracture or has had a trial and failure of zoledronic acid. The documentation does not support that 
zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on February 9, 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 injections provided on November 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injections. You say that there was an authorization on file, and you would 
like the claim paid. The Plan denied your request. The Plan says the rendering provider is an OON provider, 
and the only approved authorization was for an office visit and not for the services that were billed. 
 
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 injections provided on November 10, 2021, by 
an out-of-network (OON) provider.