Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 36248 billed for date of service January 3, 2023. 
 
You asked the Plan to pay for code 36248. You say that this code should not be bundled. The Plan denied your 
request. The Plan says you did not bill this code with an appropriate primary procedure 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, we have confirmed that code 36248 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for code 36248 billed for date of service January 3, 2023.
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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cala transcutaneous afferent patterned stimulation 
(TAPS) therapy (K1018, K1019). 
 
You asked the Plan to pre-approve Cala TAPS Therapy. You say that you request reconsideration of the denial 
of Cala TAPS therapy for the enrollee. The Plan denied your request. The Plan says this service is considered 
experimental/investigational as there is insufficient clinical evidence to support the efficacy. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of Cala TAPS therapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve Cala transcutaneous afferent patterned stimulation (TAPS) therapy (K1018, K1019).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 05, 2023, to May 10, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were 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 psychotherapy provided 
on April 05, 2023, to May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D assay (82306) provided on May 18, 2023. 
 
You asked the Plan to pay for the Vitamin D assay. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have a covered diagnosis for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that Vitamin D testing is covered when prescribed for 
one of the indications listed in the rules section of this letter. 
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has a covered 
diagnosis for this testing. Based on this information, we decided that Medicare rules for coverage of the 
Vitamin D assay have not been met. Therefore, we decided that the Plan does not have to pay for the Vitamin 
D assay (82306) provided on May 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has anemia of chronic kidney disease. The documentation does not support that the enrollee 
has tried and failed Retacrit. The documentation does not support that Retacrit would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and 
appropriate. 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  R39.15 has an Excludes1 note in relation to N39.41. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the lab services have not been met. Therefore, we decided that the Plan does not have to pay 
for lab services provided on April 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on May 4, 2023. 
 
You asked the Plan to pay for the opioid treatment services. You say that your facility is Medicare-certified to 
provide these services. The Plan denied your request. The Plan says that the billing provider is not Medicare-
certified to provide opioid treatment services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that your facility is not 
Medicare-certified to provide opioid treatment services.  This simply is not true.  Not only have you supplied 
evidence of such certification, but Medicare's own Opioid Treatment Program (OTP) Directory lists your 
facility as being certified to provide OTP services from April 18, 2004, to present. As such, we find that the 
Plan has not substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid 
treatment services provided on May 4, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an endodontist. 
 
You asked the Plan to pre-approve the dental services. You say that that you are in pain and require this 
procedure. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
consultation with an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-79 billed for date of service 
November 17, 2022. 
 You asked the Plan to pay for procedure code 99214-79. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 99214-79 is bundled into payment for 
code 20553. 
 
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 
99214-79 is a column II code to column I code 20553. 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 99214-79 billed for date of service 
November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 31, 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 (0012M) provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are pre-diabetic and 
you believe this is the only way that you will be able to prevent diabetes. The Plan denied your request. The 
Plan says medical nutritional counseling is covered for members with a diagnosis of diabetes or renal disease. 
There is no documentation or evidence of diabetes and no evidence of a reduction in renal function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29540 billed for date of service May 8, 2023.  
 
You asked the Plan to pay for procedure code 29540. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29540 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29540 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29540 billed for date of service May 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve Tezspire. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Tezspire.  
 
Benefits for Tezspire may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance (A4239) provided on May 30, 2023. 
 
You asked the Plan to pay for the supply allowance. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says this service was not billed with the appropriate 
modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code, A4239, is covered when billed 
with the appropriate modifiers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supply allowance have not been met. The record does not support that the claim was billed with 
the appropriate modifiers. Therefore, we decided that the Plan does not have to pay for the supply allowance 
(A4239) provided on May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing to be billed with codes 81161, 81400, 
81403, 81404, 81405, 81406, 81407 and 81408. 
 
You asked the Plan to pre-approve the genetic testing billed. You say that you are appealing the denial for 
genetic testing. The Plan denied your request. The Plan says panel testing should be billed using one CPT code 
on the claim. 
 
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 is an NGS panel that was needs to be 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 pre-approve the genetic testing 
to be billed with codes 81161, 81400, 81403, 81404, 81405, 81406, 81407 and 81408.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay $310.01 more for the cataract surgery. We decided that the Plan does not 
have to pay the full $3000 reimbursement you are requesting.  
 
You asked the Plan to pay more for cataract surgery you had on April 24, 2023. You say that you have been 
under-reimbursed.  You said that you should be paid 70-80% of the full $3000 that you paid up front for this 
surgery. The Plan says that you have been reimbursed correctly for this surgery. 
 
We decided that the Plan has to pay you an additional $310.01 for the cataract surgery.  
 The Plan follows Medicare rules. Medicare rules say that the Plan has to pay the Medicare-allowed rate for 
services rendered.  In this case, the Plan has reimbursed you a total of $588.28 for the cataract surgery you had.  
The corrected claim form you submitted indicates that the services were provided at an Ambulatory Surgery 
Center (ASC).  The Medicare-allowed rate for code 66984 at an ASC in Kings County (where the services 
were rendered) is $1,283.27.  Since you have a 30% coinsurance obligation, this means that the Plan should 
have reimbursed you $898.29 ($1,283.27 x 70% = $898.29).  Because the Plan only reimbursed you $588.28, it 
means that the Plan owes you an additional $310.01.     
 
We also decided that the Plan does not have to pay the full $3000 reimbursement you are requesting. 
 
As noted above, the Plan has only underpaid this claim by $310.01.  The Plan cannot be obligated to pay more 
than the Medicare-allowed rate (minus your applicable 30% coinsurance) for the surgery you had. Please note 
that we understand that your provider (incorrectly) advised you that those on Original Medicare get a full 
$3000 covered towards cataract surgery.  This is not true based on the codes you have supplied on your claim 
form. Original Medicare would only pay the full allowed amount, which is $1,283.27.  As a Medicare provider, 
the out-of-network facility where you received this surgery should not have charged you more than the 
Medicare-allowed amount.  You have the right to go back to the provider to request a refund, but the Plan 
cannot be obligated to pay more than the total of $898.29 as explained above. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care on December 13, 2021. 
 
You asked the Plan to pay for nursing facility care. You say that you did not know that the claim needs to be 
billed to the Plan as primary. The Plan denied your request. The Plan says that their first decision to deny 
payment for the service was correct. 
 
  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for nursing facility care was not filed until July 8, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for nursing facility care on December 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 3, 2023, to July 
2, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 3, 2023, to July 2, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service April 17, 
2023. 
  You asked the Plan to pay for procedure code 99140. You say that the attached medical records should be 
reconsidered, and the claim reprocessed for payment. The Plan denied your request. The Plan says procedure 
code 99140 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service April 17, 2023.