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

 
We decided that the Plan does not have to pre-approve the placement of a sprint peripheral nerve stimulation 
(PNS) device. 
 
You asked the Plan to pre-approve the placement of a sprint PNS device. You say that the enrollee's condition 
requires the requested procedure to minimize the enrollee's pain level. The Plan denied your request. The Plan 
says the requested procedure is not a covered benefit for the enrollee's condition. 
 
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 placement of a sprint PNS device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested procedure would be considered experimental/ 
investigational therapy, as the approach is the subject of ongoing clinical trials. 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 placement of a sprint PNS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the placement of a sprint peripheral nerve stimulation (PNS) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided on March 29, 2023. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter are met. 
 
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 pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that there was no 
indication to perform definitive testing beyond the opiate drug class. The other drug class testing was not 
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 the definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that you claim that you billed with a valid DEX code 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. Please note that although you claim that you billed with a valid DEX code, there is 
no DEX code in the required location on the claim you submitted. You placed the DEX code in the Remarks 
field. However, it should be entered in an electronic claim at Loop 2400/SV101-7. Because you have entered 
the DEX code in the remarks section, this is not valid.   
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 in the correct area of the claim submission. 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 February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 90832 billed for date of service June 27, 2023. 
 
You asked the Plan to pay for code 90832. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says there is no evidence that the provider of this service 
consulted or attempted to consult with the enrollee's primary care physician as is required.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 90832 have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for code 90832 billed for date of service June 27, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
17, 2022. 
 
You asked the Plan to pay for the ED services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in 
Medicare and cannot receive payment for services. We looked at the file and Medicare rules. We find that the 
provider at issue is not affiliated with a hospital and cannot receive Medicare payment.  Therefore, we decided 
that the Plan does not have to pay for the emergency department (ED) services provided on July 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on April 19, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON ophthalmology services. You say that the network doctors told you that 
they couldn't handle your situation. You said that you realized this provider was out-of-network, but you agreed 
to pay $400 for an exam and analysis. The Plan denied your request. The Plan says 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 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 these items/services. Therefore, we 
decided that the Plan does not have to pay for ophthalmology services provided on April 19, 2023, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 rendered on March 7, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 27335 is "Arthrotomy, with synovectomy, knee; anterior 
AND posterior including popliteal area."  
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 27447 includes the code 
27335 in this case as the documentation does not show that this is a separate procedure in the knee surgery. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 27335 rendered on March 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service March 28, 
2022, to April 26, 2022. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the NOA was 
not received timely. 
 
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 27, 2022. The NOA was not received by the Plan until July 5, 
2022. 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 the home health care billed for 
dates of service March 28, 2022, to April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral endoscopic pyloromyotomy (43999, 43235). 
 
You asked the Plan to pre-approve an oral endoscopic pyloromyotomy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this procedure has not been shown to be a safe or 
helpful treatment for your condition. 
 
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 an oral endoscopic pyloromyotomy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that oral endoscopic pyloromyotomy is considered investigational and 
does not fulfill criteria for coverage. 
 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 oral endoscopic pyloromyotomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an oral endoscopic pyloromyotomy (43999, 43235).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk continue falls, skin 
breakdown/wounds, and re-hospitalization. The Plan denied your request. The Plan says the enrollee's records 
do not show complex rehabilitation needs which necessitate a physiatrist, or a needed intensive team for care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The medical 
records supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 94640 billed for date of service 
May 18, 2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are covered by the fee schedule. The 
Plan denied your request. The Plan says the services are not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 93005 and 94640 have a Q1 status indicator. These codes are not separately payable 
when billed on the same claim as 99284, which has a V status indicator. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 93005 and 94640 billed for date of service May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on January 25, 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 lab panel 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 January 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed with diagnosis codes F17.210 
and Z87.891 provided on June 20, 2023. 
 
You asked the Plan to pay for procedure code 71271. You say that you would like the Plan to reconsider their 
denial of payment. 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 Z87.891 has an Excludes1 note in relation to F17.210. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure code 71271 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 71271 billed with diagnosis codes F17.210 and Z87.891 provided on June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer provided on June 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the nebulizer. You say that no authorization was required for the nebulizer. The 
Plan denied your request. The Plan says this item 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 says 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 durable medical equipment is not covered. 
 
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 item 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 this item. Therefore, we 
decided that the Plan does not have to pay for the nebulizer provided on June 15, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Point Designs Point Digit prosthesis (L7499). 
 
You asked the Plan to pre-approve the Point Digit prosthesis. You say that this prosthesis is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the Point Digit prosthesis. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records do not document that the requested prosthesis meets but does not exceed 
the patient's needs. The records do not document why a standard L6000 partial hand prosthesis would not meet 
the enrollee's needs. 
 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 Point Digit prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Point Designs Point Digit prosthesis (L7499).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service March 21, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that the documentation supports the services 
provided. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. The documentation does show the additional units were provided. The 
documentation, however, does not provide rationale as to why excess units were needed to treat the enrollees 
condition. Based on this information, we decided that Medicare rules for coverage of procedure code 88377 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88377 billed 
for date of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency telehealth visit provided on May 23, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the emergency telehealth visit. 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 certain out-of-network telehealth services are not covered. 
 
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 this service. Therefore, we 
decided that the Plan does not have to pay for the emergency telehealth visit provided on May 23, 2023, by an 
OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) (93226) 
provided on June 13, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG) (93226). You say that the service 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostics tests and therapeutic servicesand supplies. 
 
You have been asked to pay a $40 copayment for the electrocardiogram (EKG) (93226). This item/service falls 
within the outpatient diagnostics tests and therapeutic servicesand supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the electrocardiogram (EKG) (93226) provided on June 13, 2023.