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

 
We decided that the Plan does not have to pay for the nerve conduction studies provided on June 16, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the nerve conduction studies. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says these services are not covered when received by 
an out-of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network outpatient diagnostic testing and therapeutic 
services are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nerve conduction studies provided on June 16, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on July 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100 x 68). 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you have dialysis 
three times per week. You say that you need additional trips so that you can get to your remaining treatments. 
The Plan denied your request. The Plan says additional trips beyond the allowed benefit are not covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100 x 68).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's continued care needs include, monitoring 
renal function, goal directed therapy for heart failure, wound care, rehabilitative therapy being provided in the 
current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 3, 
2023, by an OON provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are appealing the denial 
with supporting documentation. The Plan denied your request. The Plan says this service is not covered when 
received by an out-of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan has a POS option to use either network providers or out-of-network providers for certain covered services. 
The Plan contract also says that out-of-network skilled nursing facility care is not covered.  
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 3, 2023, by 
an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee requires LTACH services. The 
Plan denied your request. The Plan says the enrollee is allowed 150 lifetime days for inpatient admissions. The 
enrollee has exhausted inpatient admissions benefits. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues, appears to be 
ventilator dependent, and still requires acute care services. The enrollee continues to receive acute care 
services, and these services have not been denied. The medical record does not indicate that the enrollee requires services that she is not already receiving, but that would be available at an LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for balance programs and chair yoga classes provided 
on January 1, 2022, under the 2022 wellness allowance benefit.  
 
You asked the Plan to reimburse you for balance programs and chair yoga classes under the 2022 wellness 
allowance benefit. You say that you were unaware there was a March 31st deadline and didnt think there was 
one last time. The Plan denied your request. The Plan says your reimbursement request for the 2022 wellness 
allowance benefit was not received by the Plan until June 21, 2023.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Plans rules for coverage of gym benefits have not been met because your reimbursement request for the 
2022 wellness allowance benefit was not received by the Plan until June 21, 2023. Therefore, we decided that 
the Plan does not have to reimburse you for balance programs and chair yoga classes provided on 
January 1, 2022, under the 2022 wellness allowance benefit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by code 71275-26 billed on 
May 22, 2023. 
 You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because they are supported in the documentation and were billed with a correct modifier. The Plan 
denied your request. The Plan says the radiology services are denied because they were billed without a 
required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for services furnished to 
individuals in the custody of police or other penal authorities only if the conditions laid out in 42 CFR 411.4(b) 
are met. The rules also say providers must use modifier -QJ to indicate services provided to a prisoner meet 
these conditions. 
 
We looked at the file and Medicare rules. We confirmed that the institutional claim billed for date of service 
May 22, 2023, indicated the enrollee had a discharge status of 21, defined as discharge to court or law 
enforcement. The radiology services were also billed on May 22, 2023, so the enrollee was in custody of the 
police or other penal authorities on the date these services were performed. Per Medicare rules, payment may 
only be made for services rendered to individuals who are in the custody of the police or other penal authorities 
when the conditions laid out in 42 CFR 411.4(b) are met and the services in question are reported with modifier 
-QJ to indicate this fact. We also confirmed that in this case, the radiology services were billed without 
modifier -QJ. Based on this information, we decided that Medicare rules for coverage of the radiology services 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiology services 
described by code 71275-26 billed on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 14, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 the office visit provided 
on June 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 21, 2023, to June 
19, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was billed within the timeframe. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan says that although your appeal letter contends the NOA was submitted, none has been 
received. 
 
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 NOA was not received by the Plan. As a result, 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 May 21, 
2023, to June 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 22, 2022. 
 
You asked the Plan to pay for the medical services. You say that the medical records support the billing of this 
claim. 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 N18.9 has an Excludes1 note in relation to N28.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. 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 must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 10, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) for the 
lumbar spine (22514). 
 You asked the Plan to pre-approve a lumbar PVA. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not support that the enrollee has a compression 
fracture that is in the acute or subacute time frame, within 12 weeks. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation (PVA) is 
covered in patients with an acute or subacute compression fracture. 
 
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 lumbar PVA. Our reviewer says that 
the requested lumbar PVA is not medically necessary. Our physician reviewer found detailed documentation is 
not clear regarding an acute or subacute compression fracture. The provided bone density exam from 2015 did 
not demonstrate any osteoporosis in the lumbar spine. Additionally, there is no documentation of a progression 
of the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes 
of pain. Therefore, the reviewer found that the requested lumbar PVA 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 a lumbar PVA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) for the lumbar spine (22514).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections. 
 You asked the Plan to pre-approve Botox injections. You say that the requested drug is medically necessary for 
the enrollee's treatment. The Plan denied your request. The Plan says the requested drug does not meet the step-
therapy requirements necessary for approval. 
 
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 Botox injections. Our reviewer says 
that the requested drug does not meet the criteria necessary for approval. Our physician reviewer found the 
Plan requires a trial of Xeomin before they will approve the requested drug. Based on the medical records 
provided and the Medicare-approved major drug compendia, there is no indication that the enrollee has tried 
and failed the required drug or that the plan's required drug would likely be less effective or 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 Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 20, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were billed correctly. 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 R52 has an Excludes1 note in relation to G89.29. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee requires continued wound care and skilled 
therapies to improve your functional status at the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99224 billed for date of service December 29, 2022. 
 
You asked the Plan to pay for code 99224. You say that this claim was billed correctly. The Plan denied your 
request. The Plan says you billed this service with an incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99224 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99224 billed for date of service December 29, 2022.