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

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service July 12, 
2022. 
 You asked the Plan to pay for procedure code 74176. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74177. 
 
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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service July 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan. 
 
You asked the Plan to pre-approve Lumigan. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 Lumigan.  
 Benefits for Lumigan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99202) provided May 9, 2022, to 
May 31, 2022. 
 
You asked the Plan to pay for the office visits. You say that because you have a travel pass, you are told you 
have the right to present and claim the monies out of your pockets to be reimbursed by the Plan. The Plan 
denied your request. The Plan says the services was rendered by a provider that does not participate in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient office visits (99202) 
provided May 9, 2022, to May 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the records support that the procedure was 
performed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE). 
 
You asked the Plan to pre-approve a WCE. You say that if this procedure is denied, the enrollee will need a 
more invasive procedure. The Plan denied your request. The Plan says the Medicare criteria have not been met 
because the enrollee has not had a recent colonoscopy. 
 
The Plan follows Medicare rules. Medicare rules say that a WCE is indicated for coverage for certain 
conditions listed in the Medicare rules section of this letter. 
 
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 WCE. Our reviewer says that a WCE 
is not reasonable and necessary for the enrollee. Our physician reviewer found the records do not support 
ongoing symptoms to raise undue concern for obstruction, nor for small bowel tumors that may otherwise have 
been identified on their three recent serial computed tomography scans. Our reviewer found that a WCE in the 
enrollee's case may be relatively contraindicated given their recent partial small bowel obstruction of uncertain 
cause. Our physician reviewer also found that the available records do not demonstrate the adequacy of clinical 
evaluation to date to meet medically necessary exception criteria for a WCE in evaluation of the enrollee's 
cluster of peri-jejunal mesenteric lymph nodes. 
 
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 WCE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a wireless capsule endoscopy (WCE).
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 2, 
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 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 18, 2022 to 
February 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary. 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 18, 2022 to 
February 3, 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 you are not able to take care of yourself, that's why 
you need to go to rehab before you go back home. The Plan denied your request. The Plan says the request is 
not medically necessary, the services you need can be provided safely in other settings, for example, a skilled 
nursing 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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 26, 2022, to 
May 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 April 26, 2022, to May 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment. The Plan denied your request. The Plan says it is not an accepted standard of practice 
for the treatment of back pain. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care evaluation and management 
services (99231) provided August 10, 2022. 
 You asked the Plan to pay for the subsequent hospital care. You say that the 99231 charge is not for anesthesia 
follow up, but rather for more complex/higher risk acute post-operative pain management. Please review this 
charge for reconsideration of payment. The Plan denied your request. The Plan says separately billed services 
have been bundled as they are considered components of the same procedure. Separate payment is not allowed. 
 
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 the 
subsequent hospital care is an add-on code and has not been billed with an appropriate primary procedure code. 
Payment may not be made for services included in the anesthesia care package when furnished by the same 
provider or the same provider specialty within a group practice. Anesthesia care packages consist of pre-op 
evaluation, standard operation, and monitoring services, administration of anesthesia and post-op anesthesia 
recovery care   Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care evaluation and management services 
(99231) provided August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) urinary tract infection 
(UTI) panel provided on February 22, 2022. 
 
You asked the Plan to pay for the PCR UTI panel. You say that you would like this claim to be reconsidered 
for payment. The Plan denied your request. The Plan says the service is 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 pay for the PCR UTI panel. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee had a urinary tract infection for which they were treated. 
The provided records are insufficient to establish the medical necessity, as defined by Medicare rules, of the 
requested test for the enrollee's clinical condition. Our reviewer found that the elements of the coverage criteria 
are not satisfied, and the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PCR UTI panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the polymerase chain reaction (PCR) urinary tract infection (UTI) panel provided on 
February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit received on July 7, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that you paid your $10 copayment and 
feel that is all you should have to pay. 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. Your 
contract with the Plan says that there is a $500 deductible. This is the amount you have to pay out=of-pocket 
before the Plan will pay their share for your covered medical services. 
 
The item or service you asked the Plan to waive the deductible for falls within the combined in-network and 
out-of-network deductible benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible which applies to the office visit received. This cost sharing is a 
contractual obligation that had not been met at the time the office visit was received on July 7, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for the office visit received on July 7, 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 enrollee is a fall risk and in danger at home, their 
family is afraid for enrollee to come home in their condition. The Plan denied your request. The Plan says the 
request is not medically necessary, the services the enrollee needs can be provided safely in other settings, for 
example, a skilled nursing 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 the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
 
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 vascular stenting. 
 
You asked the Plan to pre-approve vascular stenting. You say that this is medically necessary and a delay could 
jeopardize the enrollee's health. The Plan denied your request. The Plan says the enrollee has not tried and 
failed maximum medical treatment first. 
 
The plan follows Medicare rules. Medicare rules state that endovenous stenting may be covered under certain 
indications. 
 
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 vascular stenting. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested vascular stenting. Our physician reviewer 
found the documentation of the enrollee's symptoms is insufficient. This is particularly important as the 
enrollee has a history of 3 back surgeries, right knee surgery, and severe enough angina that the enrollee is 
being scheduled for heart catheterization. The description of pulses is also vague and incomplete and not 
accomplanied by objective information. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular stenting have not been met. Therefore, we decided that the Plan does 
not have to pre-approve vascular stenting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services, inpatient hospital care, 
outpatient diagnostic tests and office visits provided from January 24, 2022, to April 20, 2022. 
 
You asked the Plan to waive the copayment for ambulance services, inpatient hospital care, outpatient 
diagnostic tests and office visits. You say that you disagree with the copayments. 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). Your contract with the Plan clearly says that you must pay a $265 copayment for ambulance services, a $300 copayment per day for days 1-5 for impatient hospital care, a $95 
copayment for each outpatient diagnostic tests and a $20 copayment physician/practitioner services office visit.  
 
You have been asked to pay a $265 copayment for ambulance services, a $300 copayment per day for days 1-5 
for impatient hospital care, a $95 copayment for each outpatient diagnostic tests and a $20 copayment per 
office visits. The total amount for inpatient hospital care is $1,500 ($300 x 5days = $1,500). The total amount 
for diagnostic testing is $190 ($95 x 2= $190). The total amount for the office visits is $40 ($20 x 2 visits 
=$40). The total amount you are being asked to pay for all services rendered is $1,975 ($265 + $190 + $1,500 + 
$40 = $1975). This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for ambulance services, inpatient hospital care, 
outpatient diagnostic tests and office visits provided from January 24, 2022, to April 20, 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 you say that you need the rehab and that your 
doctors will not let you leave. The Plan denied your request. The Plan says the request is not medically 
necessary, the services you need can be provided safely in other settings, for example, a skilled nursing 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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
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.