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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 14, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 17, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI edit was made in error. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier 
indicator of 0. The column II code is therefore not payable. Any potential changes to the modifier indicator 
were not in effect at the time of service or when the claim was submitted. Based on this information, we have 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 81456 billed for date of service January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (PWC) and accessories. 
 
You asked the Plan to pre-approve a heavy-duty PWC and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the weight requirements for 
the requested wheelchair. 
 The Plan follows Medicare rules. Medicare rules say that a Group 1 PWC (K0813, K0814, K0815, K0816) or a 
Group 2 PWC (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) is covered if 
all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiarys 
weight. If the PWC base is not covered, then related accessories will be denied. 
 
The file shows that the enrollee does not meet the weight requirement for the requested PWC. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a heavy-duty power wheelchair (PWC) and accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2022, 
through August 28, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim should be paid as billed. The 
Plan denied your request. The Plan says an invalid primary diagnosis was reported, and the recertification 
OASIS assessment was not done within the 5-days before the next 60-day episode of care. 
 
The Plan must follow Medicare rules. Medicare rules say that HH PPS payment is based upon the claim data as 
well as the OASIS assessment. The OASIS assessment for recertification of another 60 days of care must be 
done within the five days preceding the next episode of care. 
 
We looked at the file and Medicare rules. In this case, the episode of care for this claim began on July 30, 2022. 
The OASIS assessment was done on July 23, 2022, which is not within the 5 days preceding the new episode 
of care. Based on this information, we decided that Medicare rules for coverage of the home health services 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from August 1, 2022, through August 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
September 14, 2022, through September 20, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the hospital with a Schatzker type III lateral tibial plateau fracture 
treated with a brace, pain medication, fluids, and was in no acute distress, with laboratory results showing 
slight anemia, a slightly elevated blood urea nitrogen (BUN) level, stable chronic atrial fibrillation, and stable 
chronic congestive heart failure. The plan was to do physical therapy, no surgery, with follow-up x-rays in four 
weeks. Based on the stability of the enrollee and no plan for surgical intervention, it was not expected that she  
would have required hospital services that would have likely crossed two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from September 14, 2022, through September 20, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has neovascular (wet) age-
related exudative macular degeneration. She has not tried and failed the Plan's required drug, bevacizumab. The 
records do not show that the required drug would be contraindicated or less effective; therefore, Vabysmo is 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vabysmo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0315U for date of service March 10, 2023. 
 
You asked the Plan to pay for procedure code 0315U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 0315U is Oncology (cutaneous squamous cell 
carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), 
utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, 
Class 1, Class 2A, Class 2B). 
 
We find that CPT code 0315U is not supported in the medical record. Specifically, the medical records 
submitted include a test result for the billed test with a result date of March 16, 2023. However, the records indicate that the date of specimen collection was on January 16, 2023. The billed date of service of March 10, 
2023, cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure 
code 0315U have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
0315U for date of service March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc procedure. 
 
You asked the Plan to pre-approve the Via Disc procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is considered experimental and therefore is not 
covered. 
 
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 Via Disc procedure. Our reviewer 
says that the requested Via Disc procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollees back pain. It is not an accepted standard of medical practice for the 
diagnosis or treatment of back pain. The requested injection of allograft (in this case, VIA Disc NP) into the intervertebral disc for the treatment of degenerative disc disease, is considered experimental and 
investigational. Therefore, the reviewer found that the requested VIA Disc procedure is not medically 
reasonable or 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 Via Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Via Disc procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 23, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this service was billed appropriately and is 
separately payable. The Plan denied your request. The Plan says payment for code 81456 is bundled into 
payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), supplies and 
accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. You say that the medical records 
support the need for the CGM, supplies and accessories. The Plan denied your request. The Plan says the 
enrollee is not treated with insulin and does not have any documented hypoglycemic events.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM, supplies and accessories. Our 
reviewer says that the CGM, supplies and accessories are not medically necessary. Our physician reviewer 
found coverage criteria for CGM require low blood glucose sugar or insulin use. We are not told of low blood 
glucose sugar levels and the enrollee is not on a medication that typically causes low blood glucose sugar. We 
are also not told why a fingerstick monitoring would not suffice. Although the CGM may help the enrollee, 
coverage criteria for CGM are not met. 
 
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 CGM, supplies and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM), supplies and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on March 27, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary artery catheterization (93458). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that this is medically necessary for the 
enrollee. 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 outpatient procedure. Our reviewer 
says that the requested cardiac catheterization is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicates the enrollee had a cardiac computed 
tomography (CT) scan consistent with possible mild coronary artery disease; however, has not had a (non-
invasive) stress test. The documentation provided do not support the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. Therefore, the reviewer found that the requested cardiac catheterization is not medically reasonable or 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve coronary artery catheterization (93458).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Crohn's disease. She 
has not tried and failed the Plan's required drugs, Remicade, Inflectra, or infliximab and Stelara. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Entyvio is not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 17, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 88360 billed for date of service April 5, 
2023.  
 
You asked the Plan to pay for procedure code 88360. You say that this service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88360 is 6. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nexwave transcutaneous electrical nerve stimulation 
(TENS) unit (E0745) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a Nexwave TENS unit. You say that please review and reprocess the 
authorization accordingly. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 
a Nexwave transcutaneous electrical nerve stimulation (TENS) unit (E0745) to be provided by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided on March 20, 2023. 
 
You asked the Plan to pay for the PT services. You say that the primary diagnosis is the same one that is on the 
authorization. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.50 has an Excludes1 note in relation to S39.012D. This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the PT services have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy (PT) services provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy services provided on January 19, 2022, 
through November 8, 2022. 
 
You asked the Plan to pay for the message therapy. You say that the services should be covered. The Plan 
denied your request. The Plan says these services were obtained through a provider that is not enrolled 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 massage therapy services provided 
on January 19, 2022, through November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 23, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI edit was made in error. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier 
indicator of 0. The column II code is therefore not payable. Any potential changes to the modifier indicator 
were not in effect at the time of service or when the claim was submitted. Based on this information, we have 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 81456 billed for date of service May 23, 2023.