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 7, 
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 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99308 and 99309 for date of service January 
8, 2023, to January 24, 2023. 
 
You asked the Plan to pay for procedure codes 99308 and 99309. 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. 
 
We find that CPT codes 99308 and 99309 are not supported in the medical record. Specifically, no medical 
records were provided to support the services billed for these dates of service. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99308 and 99309 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99308 and 99309 for date of service January 
8, 2023, to January 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on May 3, 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 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options, patient weight capacity up to and including 300 pounds (K0861), electronic connection 
(E2311), harness (E2313), expandable controller (E2377), cushioned headrest (E0955), anterior tilt (K0108), 
and additional items and accessories (codes E0953, E0956, E1007, E1012, E1028, E2300, E2323, E2361, 
E2607, and E2620). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you are requesting 
approval of a group 3 power wheelchair as previously recommended. You also say that the items are medically 
necessary when anticipating the enrollee's needs. The Plan denied your request. The Plan says the enrollee does 
not have medical need for multiple power options available with a K0861 group 3 power wheelchair. An 
expandable controller, harness, electronics, and headrest are not medically needed. The Plan also says an 
anterior tilt does not serve a medical purpose and cannot be covered.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee does not require a power wheelchair to complete MRADLs. The 
enrollee is independent in the home with a manual wheelchair. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power 
options, patient weight capacity up to and including 300 pounds (K0861), electronic connection (E2311), 
harness (E2313), expandable controller (E2377), cushioned headrest (E0955), anterior tilt (K0108), and 
additional items and accessories (codes E0953, E0956, E1007, E1012, E1028, E2300, E2323, E2361, E2607, 
and E2620).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 20, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan did not receive the primary carriers Explanation of Benefits 
(EOB). 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan contacted the 
provider to obtain the primary EOB as they did not submit the EOB with the appeal and after multiple 
outreaches to provider the Plan did not receive the primary EOB. As the secondary insurer, the Plan cannot be 
held responsible for the physician's services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on  
September 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 15-21 drug classes (G0482) provided on 
December 8, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 15-21 drug classes. You say that only 13 drug 
classes were tested. The Plan denied your request. The Plan says that this claim should be paid. 
 
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 G0482 is definitive drug testing of 15-21 classes. 
 
We looked at the file and Medicare rules. Specifically, we reviewed the claim and confirmed that 15-21 classes 
of drugs were tested. Based on this information, we decided that Medicare rules for coverage of the definitive 
drug testing of 15-21 drug classes have been met. Therefore, we decided that the Plan has to pay for the 
definitive drug testing of 15-21 drug classes (G0482) provided on December 8, 2022.  
 
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 podiatry services provided on April 18, 2023. 
 
You asked the Plan to pay for podiatry services. 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 podiatry services 
provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83789-59) provided May 8, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the medical records received do not support that the procedure or service was 
distinct or independent from other services performed; this means the use of the 59 modifier is 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, we have confirmed that code 83789 is a column II code to column I code G0480; however, 83789 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory service. Our reviewer found there is no 
documentation to support 83789 as the lab testing is covered in the G0480. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (83789-59) provided May 8, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on April 27, 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 April 27, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. 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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. The records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further deterioration. You have had 
instruction in a home exercise program and per the September 28, 2023, physical therapy note is independent in 
this program. You do not require ongoing skilled therapy beyond what the plan approved.  

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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins, 1 extremity; 10-20 
incisions (37765) and stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (37766). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services.  
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are > than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
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 enrollee does not meet criteria for coverage of the requested services. Our physician reviewer found that for 
tributary vein treatment such as stab phlebectomy to be considered medically necessary per coverage criteria, 
there needs to be persistent significant symptoms following successful treatment of truncal (saphenous) reflux 
with these symptoms existing more than 6 weeks after the reflux was treated and despite conservative efforts. 
Additionally, the veins to be treated need to be at least 4 mm in diameter. This criterion is only met for a single 
vein measuring 6 mm. As the enrollee has not yet undergone saphenous vein reflux treatment, the above 
criteria have not been met. The health plan does not provide coverage for simultaneous saphenous reflux 
treatment and tributary treatment. A rationale for this is that many patients experience satisfactory relief with 
the truncal intervention alone. 
 
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 stab phlebectomy of varicose veins, 1 extremity; 10-20 incisions (37765) and stab 
phlebectomy of varicose veins, 1 extremity; more than 20 incisions (37766).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on May 17, 2023. 
 
You asked the Plan to pay for physicians services. You say that they were the only provider available to 
provider medicallynecessary services to the enrollee. 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 physicians services 
provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the patient's doctor ordered this testing. 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 June 23, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection of an anesthetic or steroid into the genicular nerve 
(64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee does not have a knee joint 
due to an above the knee amputation. You say the superior medial and lateral genicular nerves are still present 
and able to cause chronic pain as they are located at the distal end of the femur above the knee joint. The Plan 
denied your request. The Plan says that the request does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found continuous nerve blocks can be of substantial benefit in the treatment of phantom 
limb and stump pain. The procedure is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have been met. Therefore, we decided that the Plan has 
to pre-approve injection of an anesthetic or steroid into the genicular nerve (64454).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 18, 
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 April 18, 2023.