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

 
We decided that the Plan does not have to pay for procedure code 36558 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for procedure code 36558. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 36558 is: Insertion of tunneled centrally inserted central 
venous catheter, without subcutaneous port or pump; age 5 years or older. 
 
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 procedure code 36558. Our reviewer says that procedure code 36558 does not meet criteria for payment. Our reviewer found that the provided procedure report does not 
include sufficient documentation of termination of catheter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 36558 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 36558 billed for date of service March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Checkpoint kinase 2 (CHEK2) genetic testing. 
 
You asked the Plan to pre-approve CHEK2 genetic testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for 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 CHEK2 genetic testing. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you have a history of melanoma. The documentation does not show that the 
results of the testing will directly impact treatment or management. Therefore, you do not have a 
diagnosis/condition that meets criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CHEK2 genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Checkpoint kinase 2 (CHEK2) genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97110, 97140, 97162, 97597 and 
97760) provided on December 21, 2022. 
 
You asked the Plan to pay for therapeutic services. You say that these services were medically necessary and 
could not be performed by the enrollee's facility. The Plan denied your request. The Plan says the payment for 
these services is made to the skilled nursing facility where the enrollee was admitted on the date in question.  
 
The Plan must follow Medicare rules. Medicare rules say that all services billed by the SNF (including those 
furnished under arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are 
included in the SNFs Part A bill.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapeutic services have not been met. Specifically, the enrollee was in a Part A covered SNF stay 
at the time of services. This means that the payment for these services is furnished under arrangements and paid 
to the SNF facility, not to the provider separately. Therefore, we decided that the Plan does not have to pay for 
therapeutic services (97110, 97140, 97162, 97597 and 97760) provided on December 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health service plan development provided on  
June 15, 2023. 
 
You asked the Plan to pay for mental health service plan development. You say that all members that have 
Medicare DSNP coverage must pay services as per ACHA Rules effective July 1, 2021. The Plan denied your 
request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  Therefore, we decided that the Plan does not have to pay for mental health service plan development provided 
on June 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on July 27, 2023. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20610 
provided on July 27, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the drugs (J3490) provided on July 
27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
June 12, 2023, to June 13, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the inpatient admission 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee with osteoarthritis in the right knee who underwent elective right knee 
arthroplasty surgery on June 12, 2023, and was discharged on June 13, 2023. The notes did not describe the 
enrollee at a high risk with complication from surgery or other factors that would have expected the enrollee to 
need hospital services that would cross two midnights or that would lead to an adverse event if discharged 
earlier. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from June 12, 2023, to June 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99223 
billed on January 9, 2023, and 99233 billed on January 10, 2023, and January 11, 2023. 
 
You asked the Plan to pay for the evaluation and management services. You say that the evaluation and 
management services should be paid as billed because they are supported in the record. The Plan denied your 
request. The Plan says the evaluation and management services are denied because they are not supported in 
the 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. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. The CPT Code Manual definition of code 99233 is 
subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
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 evaluation and management services. 
Our reviewer says that the evaluation and management services are not supported in the documentation. Our 
reviewer found the enrollee is a 74-year-old with Parkinson's disease who was treated in the hospital. Although 
the documentation includes an appropriate history and examination for each of the billed dates, the enrollee 
was stable and there was no documentation supporting a high level of medical decision making for 99223 
billed on January 9, 2023, 99233 billed on January 10, 2023, or 99233 billed on January 11, 2023. Also, the 
duration of the appointment coded as 99223 was not documented as 75 or more minutes, as required. The notes 
from 99233 billed on January 10, 2023, and January 11, 2023, do not report a duration of 50 minutes or more, 
as required. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the evaluation and management services have not been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services coded as 99223 billed 
on January 9, 2023, and 99233 billed on January 10, 2023, and January 11, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has had a trial of Avastin. Byooviz 
is not carried in your office therefore cannot be used. The Plan denied your request. The Plan says that step 
therapy requirements 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 the medication. Our reviewer says that 
the criteria for coverage of Eylea have not been met. Our physician reviewer found that the Plan requires a trial 
of Avastin and Byooviz before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would 
likely be less effective or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 18, 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 May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80051, 82040, 82247, 82310, 82330, 82565, 
82728, 83540, 83970, 84075, 84100, 84155, 84450, 84460, 84466, 84520, 84520, 85014, 85018, 85025, 
A4657, J0604, J1756, and Q4081 related to end-stage renal disease (ESRD) provided on June 2, 2023, to June 
30, 2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services and all 
ESRD-related injectable drugs and biologicals and oral equivalents of those injectable drugs and biologicals are 
included in the ESRD PPS. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for procedure codes 80051, 82040, 82247, 82310, 82330, 82565, 82728, 83540, 83970, 
84075, 84100, 84155, 84450, 84460, 84466, 84520, 84520, 85014, 85018, 85025, A4657, J0604, J1756, and 
Q4081 related to end-stage renal disease (ESRD) provided on June 2, 2023, to June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87086, 87481 (3 
units), 87491, 87496, 87529 (2 units), and 87532 for October 20, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 items/services at issue were 
reimbursed by the Plan on December 25, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the laboratory services billed with codes 87086, 87481 (3 
units), 87491, 87496, 87529 (2 units), and 87532 for October 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit (99203) provided on April 17, 2023. 
 
You asked the Plan to pay for office visit (99203). You say that the service was medically necessary and should 
be covered. 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 office visit (99203) 
provided on April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve semi-electric hospital bed. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet criteria for a semi-electric 
hospital bed. 
 The Plan follows Medicare rules. Medicare rules state that a semi-electric hospital bed may be covered if 
certain 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 semi-electric hospital bed. Our reviewer 
says that the enrollee does not meet criteria for a semi-electric hospital bed. Our physician reviewer found a 
fixed height or variable height bed should meet the enrollee's medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unoccupied transit kit (K0108). 
 
You asked the Plan to pre-approve an unoccupied transit kit. You say that the denial of the unoccupied transit 
kit does not make the base or any other accessories unusable. You also say that the transit kit is not an integral 
part of the base, thus a split decision should be possible. The Plan denied your request. The Plan says a transit 
kit does not serve a primary medical purpose. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules also say that for equipment to be covered, it must primarily 
serve a medical purpose. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. The item at issue in this appeal also does not 
serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-
approve an unoccupied transit kit (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided June 
21, 2023. 
 
You asked the Plan to pay for the ultraviolet (UV) light therapy system. You say that you have attached the 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says this request 
is not medically necessary because the records show the enrollee does not have any clinical indication for UV 
light therapy. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record sent by the provider does not indicate that the enrollee has 
psoriasis and there is no mention in the clinical records of a plan for using UV light therapy. Outreach to the 
provider's office verified that there is no prescription or documentation related to UV light therapy in the 
enrollee's chart. Based on this information, we decided that Medicare rules for coverage of the ultraviolet light 
therapy system have not been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet 
light therapy system (E0691) provided June 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 20, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
thought that you were saving the Plan money by not being transported to the hospital. The Plan denied your 
request. The Plan says the documentation shows you were competent and did not want to be transported to a 
hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 20, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on May 
24, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you are not being reimbursed 
for the dental work. You also say that you understood that you could go out-of-network and would be 
reimbursed for most dental work and you are not seeing that so far. The Plan denied your request. The Plan says your benefit for the panoramic radiographic image has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted for a similar x-ray service D0210 on date of service 
March 2, 2023. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image 
(D0330) provided on May 24, 2023.