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

 
We decided that the Plan does not have to pay for home health services provided on June 08, 2023. 
 
You asked the Plan to pay for home health services. You say that you depend upon the hospital to verify and 
gather Plan information and authorization. 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 home health services 
provided on June 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise ball (E1399). 
 
You asked the Plan to pre-approve an exercise ball. You say that you think you will benefit from this as this 
will help to reduce your pain and will prevent you from buying medications. The Plan denied your request. The 
Plan says an exercise ball is not covered under Medicare or Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an exercise ball (E1399).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 17, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that the claim is billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 29, 
2023. 
 You asked the Plan to pay for procedure code 99497. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 
99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 3, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the Plan's denial. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backrest with push handles (K0108). 
 
You asked the Plan to pre-approve a backrest with push handles. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a backrest with push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venipuncture provided on July 17, 2023. 
 
You asked the Plan to pay for the venipuncture. You say that you are requesting reconsideration for the 
services provided. 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 venipuncture 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve unlisted multianalyte assay with algorithmic analysis (81599). 
 
You asked the Plan to pre-approve unlisted multianalyte assay with algorithmic analysis. You say that the 
services are necessary. The Plan denied your request. The Plan says that medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 unlisted multianalyte assay with 
algorithmic analysis. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found multianalyte assays with algorithmic analyses 
(MAAA) were developed toward the goal of personalized medicine, to supplement existing techniques and 
further inform the decision of whether to treat with adjuvant chemotherapy. Several gene expression profiling 
tests are now available for use in patients with breast cancer. In general, these tests provide an estimate of 
prognosis. In select instances, they may also be predictive for benefit from chemotherapy. This article reviews 
the latest studies evaluating the use of these tests. The review has determined that the items/services at issue in 
this case are 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 unlisted multianalyte assay with algorithmic analysis have been met. Therefore, 
we decided that the Plan has to pre-approve unlisted multianalyte assay with algorithmic analysis (81599).  
 
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 pay for the pneumatic compression device (E0675) and pneumatic 
appliance (E0673) provided on April 14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the pneumatic compression device. You say that the enrollee was treated for 
post-surgical edema/inflammation and post-surgical lymphedema by these services. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 requested 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 pneumatic compression device (E0675) and 
pneumatic appliance (E0673) provided on April 14, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (84153) provided on March 20, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made under the physician fee 
schedule for the professional component of physician laboratory or physician pathology services furnished to 
hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they qualify as the re-
assignee for the physician service. 
 
We looked at the file and Medicare rules. Code 84153 is not payable under the physician fee schedule and does 
not have a professional component that is payable to a pathologist. 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 the lab services (84153) provided on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22558 and 22853 for date of service July 
17, 2023. 
 You asked the Plan to pay for procedure codes 22558 and 22853. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code M41.57, defined 
other secondary scoliosis Lumbosacral region. This code is not an appropriate primary diagnosis as the code 
has a Code first note indicating to code the underlying condition first. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 22558 and 22853 for date of service July 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nuvasive Osteocel allograft (20930). 
 
You asked the Plan to pre-approve the Nuvasive Osteocel allograft. You say that the enrollee is in a lot of pain 
and is at risk of no regaining maximum functions and mobility. The Plan denied your request. The Plan says 
the clinical value and effectiveness of this allograft in the setting of lumbar decompression and fusion has not 
been demonstrated in the peer-reviewed literature. 
 
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 the Nuvasive Osteocel allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is limited published, large-scale, long-term peer-reviewed 
literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. 
Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional 
treatment. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Nuvasive Osteocel allograft 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 the Nuvasive Osteocel allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Nuvasive Osteocel allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87635 for July 3, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with code 87635 for July 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-purpose medical kitchen stool (E1399). 
 
You asked the Plan to pre-approve the kitchen stool. You say that due to your medical condition you feel this 
all-purpose kitchen stool will help you be more independent and be able to do things like cooking for yourself. 
The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an all-purpose medical kitchen stool (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 
1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee did not have a choice in 
providers due to being in a facility. Please review the claim and reconsider for payment. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 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 requested 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 subsequent nursing facility care (99308) 
provided on July 1, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, and the patient was 
treated on good faith. Please see documents and review. 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 an office visit provided 
on August 14, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the injection services billed with codes J0665, J3301, and Q9965. We 
decided that the Plan does not have to pay for the injection services billed with code G0260.  
 
You asked the Plan to pay for the injection services billed with codes G0260, J0665, J3301, and Q9965 for date 
of service August 15, 2023. You say that you disagree with the Plan's denial. The Plan says that the services are 
not payable as billed. 
 
We decided that the Plan has to pay for the injection services billed with codes J0665, J3301, and Q9965.  
 
The Plan follows 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 file does not support why these codes are being denied. This means that the 
Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the injection services 
billed with codes J0665, J3301, and Q9965 provided on August 15, 2023.  
 
We also decided that the Plan does not have to pay for the injection services billed with code G0260. 
 
The Plan follows Medicare rules. Medicare rules say that code G0260 should be reported with an imaging code 
specific to the imaging modality employed. 
 
The file does not show that you have a medical indication for which Medicare will cover code G0260. This 
code requires an accompanying imaging code to be covered. Codes 77002 or 77012 were not billed with this 
code. Therefore, we decided that the Plan does not have to pay for the injection services billed with code 
G0260 provided on August 15, 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 the PureWick urine collection system (K1006). 
 
You asked the Plan to pre-approve the PureWick urine collection system. You say that the enrollee is currently 
in a skilled nursing facility due to a fall. The enrollee used this PureWick system while in hospital and it 
worked. This is needed to ensure safety. The Plan denied your request. The Plan says the PureWick urine 
collection system is considered unproven as medical studies have not proven this to be helpful for the treatment 
urinary incontinence. 
 
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 the PureWick urine collection system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the PureWick urine collection system (K1006).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on August 26, 2023. 
 
You asked the Plan to pay for the outpatient visit. You say that you are requesting reconsideration stating the 
hospital contacted the plan regarding the services, and they were told they didnt need a referral and to bill 
without one. 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 outpatient visit 
provided on August 26, 2023.