Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. You say that this is medically necessary.  The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
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 Eylea. Our reviewer says that the 
requirements for coverage of Eylea have not been met. Our physician reviewer found the Plan requires a trial of 
Byooviz before they will approve Eylea. The provided records do not indicate that the enrollee has tried and 
failed Byooviz. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from Byooviz. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018). 
 
You asked the Plan to pre-approve a Cala Trio therapy system. You say that you are requesting reconsideration 
due to the enrollee's specific needs and the proven safety and efficacy of the technology. The Plan denied your 
request. The Plan says a review of the current medical literature does not support this Cala Trio therapy system 
to be reasonable and 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 a Cala Trio therapy system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a Cala Trio tremor stimulator device is not medically necessary per 
the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any 
items or services that are not 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 evidence in the literature that this 
device is effective for the enrollee's tremor. The requested K1018 is not the standard of care for this enrollee's 
tremor according to current guidelines. 
 
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 Cala Trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(K1018).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0326U) billed for date of service 
February 9, 2023. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was submitted with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. There are few exceptions to this rule. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, the sample in question is a blood sample 
which was collected from a non-hospital patient. This means that none of the possible exceptions to the general 
date of service rule have been met. Therefore, the appropriate date of service to report in this case would be the 
date the specimen was collected: February 2, 2023. Therefore, we decided that the Plan does not have to pay 
for Guardant360 testing (0326U) billed for date of service February 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 15, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for these services is included in the hospital payment. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to 
independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was inpatient February 13, 
2023, to February 18, 2023. Payment for these ambulance services is included in the hospital payment and are 
not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided on February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 12, 2023, to 
April 7, 2023. 
 You asked the Plan to pay for the home health services. You say that you would like an exception made for this 
claim. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
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.  
 
In this case, the start of care date is February 10, 2023. The NOA was not received by the Plan until June 8, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 12, 2023, to April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 5, 2022, billed 
with evaluation and management (EM) code 99223-AI. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99223-AI is Initial hospital care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside 
and on the patient's hospital floor or unit. 
 
We asked our coder 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that there is insufficient documentation to 
confirm and verify services provided, as well as an appropriate modifier would be appended to support 
different services provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 5, 2022, billed with evaluation 
and management (EM) code 99223-AI.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87502, 87581, 87651, 87798 and U0005 for date of 
service October 28, 2022. 
 
You asked the Plan to pay for codes 87502, 87581, 87651, 87798 and U0005. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says they have insufficient documentation to 
corroborate the services to confirm Medicare coverage has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87502, 87581, 87651, 87798, and U0005 are not payable as billed. Specifically, the 
medical records provided do not include a lab order/requisition. This means codes 87502, 87581, 87651, and 
87798 are not payable as billed. The documentation shows that infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease COVID-19), amplified probe technique was performed. This means code U0005 is not supported and there is a 
more appropriate code to be billed for the services rendered. Based on this information, we decided that 
Medicare rules for coverage of codes 87502, 87581, 87651, 87798 and U0005 have not been met. Therefore, 
we decided that the Plan does not have to pay for codes 87502, 87581, 87651, 87798 and U0005 for date of 
service October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 83789) billed for date of 
service May 16, 2023.  
 
You asked the Plan to pay for drug testing services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and code 
G0480 is not supported in the medical record. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that providers performing 
validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
In this case, the CPT Code Manual definition of code G0480 is drug test(s), definitive, includes specimen 
validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes G0480 and 83789 have not been met. Specifically, the records support that drugs from more 
than 7 drug classes were tested in this case; therefore, there is a more appropriate code to report the services 
provided. In addition, we find that the testing described by code 83789 is not separately payable. Therefore, we 
decided that the Plan does not have to pay for drug testing services (G0480, 83789) billed for date of service 
May 16, 2023.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 71045. We decided that the Plan does not have to pay for 76937.  
 
You asked the Plan to pay for procedure codes 71045 and 76937 rendered on April 14, 2023.. You say that this 
should be paid for. The Plan says that the denied codes remain not supported. 
 
We decided that the Plan has to pay for 71045.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 for CPT 71045. Our reviewer says that a chest x-ray to 
determine the location of the catheter was done and documented. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
71045.  
 
We also decided that the Plan does not have to pay for 76937. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 for CPT 76937. Our reviewer says that this code 
requires the vessel entry under ultrasound to be permanently recorded. Such documentation is lacking. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 76937 have not been met. Therefore, we decided that the Plan does not have to 
pay for 76937. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee has undergone a genicular 
block and also a right genicular radio frequency. The Plan denied your request. The Plan says this service is not 
the standard medical treatment for your condition. 
 
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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered an experimental/ investigational procedure. It is the subject of 
ongoing clinical trials. Therefore, the request genicular nerve block is not medically reasonable and 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20680 and 23474 rendered on January 19, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 20680: 
 
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)  
CPT 23474: 
 
Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component 
 
We asked our coder 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 supported by the medical records. Our reviewer found that the records do not support either 
CPT 20680 or CPT 23474. The procedure details cite the wound was thoroughly irrigated with pulse lavage 
solution several liters. The head was placed onto the actual prosthesis with some antibiotic cement used to 
assist with fixation. The antibiotic spacer stem and head were then impacted into place. Therefore, the records 
do not support that CPT 20680 or CPT 23474 was rendered in this case. 
 
We looked at this coder'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 procedure codes 20680 and 23474 rendered on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99306) rendered 
on October 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 99306 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit." 
 
We asked our coder 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 supported by the medical records. Our reviewer found that in this case, the medical records 
submitted did not support a comprehensive history or medical decision making of high complexity. 
 
We looked at this coder'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 initial nursing facility care (procedure code 99306) rendered on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that this is medically necessary. 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 US-IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. This would 
not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical Osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve an electrical Osteogenesis stimulator. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator (E0748) is 
covered only when specific criteria are met 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electrical Osteogenesis stimulator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not document that any of the conditions required for coverage under the rules have been satisfied. The elements 
of the coverage criteria are not satisfied. 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 an electrical Osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical Osteogenesis stimulator (E0748).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trimming dystrophic nails (G0127) provided on April 05, 
2023. 
 
You asked the Plan to pay for trimming dystrophic nails (G0127). You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for trimming dystrophic 
nails (G0127) provided on April 05, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 12, 2022, to 
October 11, 2022. 
 You asked the Plan to pay for the home health services. You say that the initial claim was submitted in the 
wrong format.  You said that you now have a NOA on file. The Plan denied your request. The Plan says the 
NOA was not received timely. As such, this final claim was correctly denied.  
 
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.  
 
In this case, the start of care date is September 12, 2022. The NOA was not received by the Plan until January 
23, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 12, 2022, to October 11, 2022.