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

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 21, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 21, 2023, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from May 23, 2023, to 
May 26, 2023. 
 
You asked the Plan to pay for acupuncture services. The Plan denied your request. The Plan says the provider 
was contacted and confirmed that these services were for insomnia, not lower back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, these services were for insomnia, not lower back 
pain. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from  
May 23, 2023, to May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenic stimulator (20974). 
 
You asked the Plan to pre-approve an osteogenic stimulator. 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 follows Medicare rules. Medicare rules say that noninvasive stimulator devices are covered only 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 an osteogenic stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found it does not appear that the 
enrollee meets the criteria for the osteogenic stimulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an osteogenic stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an osteogenic stimulator (20974).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 18, 2022, 
to March 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required NOA 
timely. 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 February 18, 2022, to 
March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 21, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniGraf testing provided on December 15, 2022. 
 
You asked the Plan to pay for this testing is not covered. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of this testing is 
not covered have not been met. Therefore, we decided that the Plan does not have to pay for the OmniGraf 
testing provided on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block injection (64624). 
 
You asked the Plan to pre-approve a genicular nerve block injection. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a genicular nerve block is experimental for knee pain. 
 
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 injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve block injection (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing provided on January 31, 2023.  
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says this testing is not covered as 
a screening service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the WATS cytopathology and histopathology diagnostic testing, was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic testing 
provided on January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44143 billed for date of service February 13, 
2023.  
 You asked the Plan to pay for procedure code 44143. You say that you are appealing with supporting records. 
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 44143 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 44143 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 44143 billed for date of service February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on June 1, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M are non-covered for 
CxBladder testing.  
 
We looked at the file and Medicare rules. In this case, the billed code, 0012M, is not covered for CxBladder 
testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on June 1, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 10, 2023, to 
March 11, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
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 start of care date is February 10, 2023. The NOA was not received by the Plan until April 17, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, 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 February 10, 2023, to March 11, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0429, A0425) provided on May 6, 2023. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was transported from their 
residence to the emergency room. The Plan denied your request. The Plan says that the enrollee was an 
inpatient at the time of service, so this cannot be paid separately. 
 
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. The Plan has not provided any documentation to support that the enrollee was an 
inpatient at the time of service. Without this information, the denial cannot be verified. Therefore, we decided 
that the Plan has to pay for ambulance services (A0429, A0425) provided on May 6, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physician's services provided on May 27, 2023. 
 
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 that this provider does not have a license or is a certified doctor and 
does not have an NPI registry.  
 
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 has not provided proof that this physician does not have a 
license and is not a certified doctor and does not have an NPI number to substantiate their denial. Therefore, we 
decided that the Plan has to pay for the physician's services provided on May 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 08, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on December 08, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326). 
 You asked the Plan to pre-approve Gel-One. You say that Gel-One is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Gel-One 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 Gel-One. Our reviewer says that 
treatment with Gel-One is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Synvisc, Durolane and Gelsyn-3 before they will approve the requested drug. 
The requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gel-One (J7326).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (81450) provided on November 21, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. 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 laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (81450) 
provided on November 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 19, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on July 10, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that then enrollee has been a patient at this office 
for over 20 years. You say that there has never been a problem getting paid. You also say that this should be 
reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan also says that the services were not urgent or emergent. 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service 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 office visit (99213) provided on July 10, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87640, 87653, 87651, 87493, 
87563, and 87801 billed for date of service March 23, 2023. 
 You asked the Plan to pay for procedure codes 87798, 87481, 87640, 87653, 87651, 87493, 87563, and 87801. 
You say that you disagree with the denial. The Plan denied your request. The Plan says the codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87798, 87481, 87640, 87653, 87651, and 87493 are column II codes to column I code 87801. The -59 modifier 
is not supported as a separate and distinct procedural service. Based on the claim submitted, Medicare billing 
criteria have not been met.  
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. The definition of code 87563 is infectious agent 
detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. 
 
We find that CPT codes 87801 and 87563 are not supported in the medical record. Specifically, there is a more 
appropriate lab panel code that should be billed when one ore more codes are included in the same panel. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87481, 87640, 87653, 
87651, 87493, 87563, and 87801 billed for date of service March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 6, 2023, to 
February 22, 2023. 
 You asked the Plan to pay for the home health services. You say that you have filed the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
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 start of care date is January 7, 2023. The NOA was not received by the Plan until March 24, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, 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 February 6, 2023, to February 22, 2023.