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

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on April 14, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that this should be covered. 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hospice election has been revoked or terminated.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 April 13, 2022. 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 subsequent 
hospital care (99232) provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensor (CPT code K0554). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee's fingertips are fragile after years of 
pricking. The Plan denied your request. The Plan says the enrollee should consult the provider about alternate 
site testing, which allows testing in other areas besides their fingertips. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. If the enrollee is not on insulin at least three times a day and 
changing the insulin dose based on their most recent blood glucose, Medicare does not cover the CGM or 
supplies. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Libre 2 Sensor (CPT code K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (92134) provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. You say that you were billed twice as 
though your doctor was out-of-network. You also say that you would like to appeal this because your provider 
is in-network. 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 $30 
copayment for all other Medicare-covered vision services provided in-network, and a $40 copayment for all 
other Medicare-covered vision services provided out-of-network.  
 
 
 You have been asked to pay a $30 copayment for the diagnostic imaging. This item/service falls within the 
Vision Care benefit category. 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. The record shows that you were seen by an out-of-network provider, but an edit was applied to this claim, 
and an in-network cost share was applied rather than the $40 cost share for an out-of-network provider. 
Therefore, we decided that the Plan does not have to waive the copayment for the scanning computerized 
ophthalmic diagnostic imaging (92134) provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion 
device. 
 
You asked the Plan to pre-approve the spinal device. The Plan denied your request. The Plan says this 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 pre-approve the spinal device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of 
large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. The HA Minuteman G3-R MIS Fusion Plate (and/or similar devices) is intended for use 
with bone graft material and is not intended for stand-alone use. In addition, fusion indications within 
guidelines/literature for (existing or potential intraoperative) instability have not been documented and/or met 
in this case. In addition, there are multiple alternate pain generators plausibly significantly contributing to the 
clinical condition that have not been fully documented as having been excluded and/or ruled out. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 spinal device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous platelet rich plasma (PRP) for diabetic 
chronic wounds or ulcers (3C patch system) (G0465). 
 
You asked the Plan to pre-approve the 3C patch system. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that autologous platelet rich plasma (PRP) is covered 
for the treatment of chronic non-healing diabetic wounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 3C patch system have not been met. Specifically, the provided documentation does not support 
that you have diabetes. Therefore, we decided that the Plan does not have to pre-approve autologous platelet 
rich plasma (PRP) for diabetic chronic wounds or ulcers (3C patch system) (G0465).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on March 23, 
2022, to June 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that you are requesting reimbursement. The Plan 
denied your request. The Plan says the provider is out-of-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the outpatient mental health services provided on March 23, 
2022, to June 6, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit and the coinsurance 
for injections provided from February 2, 2022, to March 9, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit and the coinsurance for injections. You 
say that you were confused on all the charges and would like them to be investigated. 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 $25 
copayment per visit for in-network specialist services and 20% coinsurance for in-network Medicare Part B 
prescription drugs. 
 
You have been asked to pay a $25 copayment per visit for specialist office visits and 20% coinsurance for 
injections.  
CPT Code Allowed Amount Coinsurance Copayment Amount Being Asked to Pay 
99213 --- --- $25 $25 
99213 --- --- $25 $25 
J3489 $23.07 20% --- $4.61 
96374 $37.73 20% --- $7.55 
 
Total Amount Being Asked to Pay: $50 + $50+ $4.61+ $7.55 = $62.16 
 
The office visits fall within the in-network specialist services benefit category, and the injection falls in the in-
network Medicare Part B prescription drugs benefit category. 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 
and coinsurance for specialist office visit and the coinsurance for injections provided from February 2, 2022, to 
March 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Privigen 10% vial. 
 
You asked the Plan to pre-approve a Privigen 10% vial. The Plan denied your request. The Plan says the 
enrollee has CLL and hypogammaglobulinemia, and their IgG level was less than 600. The Plan also says that 
the records do not say that the enrollee has had infections. 
 
The Plan follows Medicare rules. Medicare rules say that IVIG will be covered when used to prevent recurrent 
bacterial infections in patients with B-cell CLL meeting all of the 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 Privigen 10% vial. Our reviewer says 
that the enrollee does not meet the criteria for coverage. Our physician reviewer found the record indicates that 
the enrollee has CLL with an IgG level of less than 600 mg/dl. Our reviewer found that the record provided 
does not establish a recent history of serious bacterial infection(s) requiring either oral or parenteral antibiotic 
therapy. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that 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 a Privigen 10% vial have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Privigen 10% vial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) provided on 
April 30, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the service at issue was reimbursed by 
the Plan on May 4, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed service was provided twice on the same date. Based on this information, we 
decided that the Medicare rules for this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the subsequent hospital care, per day (99233) provided on April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiothoracic office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the evaluation and management services. You say that the enrollee is an 
established patient at this office. You also say that the enrollee had surgery performed by you in 2018. The Plan 
denied your request. The Plan says the requested services can be provided in-network. 
 
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 confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve cardiothoracic office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 were admitted for revision of hip arthroplasty and was discharged home on 
10/14/22. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. 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 July 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone and needs help to get back 
to baseline with their mobility. The Plan denied your request. The Plan says the criteria for admission to SNF 
have not been met. Skilled services can be provided on an intermittent outpatient basis, in a long-term care 
facility, or at the home with home health care services. 
 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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81328, 81335 and 81355. 
 
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 this claim was not billed in 
accordance with Medicare guidelines. 
 
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 
April 27, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81328, 81335 
and 81355.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 64488. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 64488 is bundled into payment for code 00840.  
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 64488 
is a column II code to column I code 00840. 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 64488 billed for date of service February 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88381 and 88360 billed for 
date of service January 26, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88381 and 88360. You say that you disagree 
with the denial The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, 88381 and 88360 have a Professional/Technical indicator of 1. This means 
that CPT codes 88341, 88342, 88381 and 88360 have both a professional and technical component. In this 
case, CPT codes 88341, 88342, 88381 and 88360 have not been billed with an appropriate modifier to indicate 
the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88381 and 88360 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88381 and 88360 billed for date of service January 26, 
2022.