Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service July 14, 2022, to 
August 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 July 14, 2022. The NOA was not received by the Plan until January 11, 
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 the home health services for 
date of service July 14, 2022, to August 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve the SPRINT peripheral nerve stimulator (PNS). You say that this is 
medically necessary. The Plan denied your request. The Plan says the SPRINT PNS system does not meet the Medicare criteria as it is not an implanted peripheral neurostimulator with a trial of implantation showing 
effective pain control. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of stimulators can be covered under 
specific conditions. 
 
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 SPRINT peripheral nerve stimulator 
(PNS). Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found 
the PNS device 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 the SPRINT peripheral nerve stimulator (PNS) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary 
artery pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of a wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from January 9, 2023, to February 6, 2023. 
 
You asked the Plan to pay for the water circulating heat pad. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says this service was not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that it has not been established that a water circulating 
heat pad with pump (E0217) is reasonable and necessary compared to a standard electric heating pad (E0210). 
 
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 water circulating heat pad. Our reviewer says that this service was not medically necessary. Our physician reviewer found that the use of the water 
circulating heat pad is not the standard of care. 
 
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 water circulating heat pad have not been met. Therefore, we decided that the 
Plan does not have to pay for the water circulating heat pad with pump (E0217) provided from January 9, 2023, 
to February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary because based on the medical literature this procedure is considered experimental or 
investigational and has not been proven to be beneficial 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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
blocks are 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 destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance (64624).
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve denosumab. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the enrollee has not tried and failed preferred medications. 
 
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 forwarded a copy of the Medical Benefits Chart or 
any medical records related to this request. Without this information, we are unable to determine if the Plan 
requires step therapy or if the requested medication meets those guidelines. It is the burden of the health plan to 
substantiate their denial with evidence. In this case, the denial is not substantiated, so we must find in your 
favor. Therefore, we decided that the Plan has to pre-approve denosumab.  
 
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 procedure code 93458 billed for date of service March 22, 
2023, to March 24, 2023. 
 You asked the Plan to pay for procedure code 93458. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93458 is bundled into payment for code 92920. 
 
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 93458 
is a column II code to column I code 92920. 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 93458 billed for date of service March 22, 2023, 
to March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on December 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was 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 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 Drug Testing, Definitive, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show only 8-14 
drug classes were tested. There is a more appropriate code for this service (G0481). 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 (G0482) provided on December 14, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service December 9, 2021, to 
January 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are included in the inpatient allowed amount. 
 
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 looked at the file and the rules. The claim information shows that the enrollee was an inpatient from 
November 23, 2021, to December 14, 2021. We find that the home health services at issue were provided on 
December 15, 20, and 27, 2021; and January 6, 2022. The enrollee was not an inpatient at the time the services 
were provided. The enrollee does not have to be discharged from home health care because of admissions to 
other types of providers. The Plan also states that the services were billed on an outpatient claim. The case file 
does not include documentation of an outpatient claim. Furthermore, the billed codes are not payable on 
outpatient claims. Based on this information, we decided that Medicare rules for coverage of the billed services 
have been met. Therefore, we decided that the Plan has to pay for the home health care billed for dates of 
service December 9, 2021, to January 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on April 17, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted 
delivery ticket shows a delivered date of April 14, 2023. The records do not show that the supplies were ordered or delivered on the billed date of service. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the supplies provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that as a lab, you do not have access to the medical 
records. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 provided on July 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services coded as 70355 performed on March 21, 2023. 
 
You asked the Plan to pay for the x-ray services. You say that the x-ray services should be covered because 
they are supported in the documentation. The Plan denied your request. The Plan says 70355 is denied because 
the record does not include an interpretation and report to support the x-ray services were performed. 
 
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 70355 is orthopantogram (panoramic x-ray). 
 
We find that CPT code 70355 is not supported in the medical record. Specifically, the record does not include a 
written interpretation and report signed by the provider to justify payment of this code. Based on this 
information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, 
we decided that the Plan does not have to pay for x-ray services coded as 70355 performed on March 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on April 15, 
2023. 
 
You asked the Plan to pay for 99285. You say that this was medically necessary. The Plan denied your request. 
The Plan says this visit was performed within the global surgical period of a procedure and was not billed with 
an appropriate modifier for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that modifiers were established to bill for visits and 
procedures which are furnished during the postoperative period of a surgical procedure. These modifiers are -79 and -24. 
 
We looked at the file and Medicare rules. This service code did not include an appropriate modifier to support 
payment during the postoperative period of a surgical procedure. Based on this information, we decided that 
Medicare rules for coverage of 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency room visit (99285) provided on April 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 4, 2023, to 
February 2, 2023. 
 You asked the Plan to pay for the home health services. You say that you are an out-of-network provider, so 
this claim was not processed correctly. 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 4, 2023. The NOA was not received by the Plan until March 1, 
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 January 4, 2023, to February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system (L5920). 
 
You asked the Plan to pre-approve an alignable system. You say that the enrollee requires an immediate 
replacement of their current socket to provide a better fit so that their residual limb can heal. The Plan denied 
your request. The Plan says the notes do not show why member's current alignable system cannot be used for 
the approved replacement socket. 
 
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 alignable system. Our reviewer says 
that the requested items is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the treating medical provider progress notes do not support that the enrollee's current alignable 
system requires replacement or is unable to be used with the new prosthetic socket therefore the request 
exceeds the enrollee's medical 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 an alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an alignable system (L5920).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 7, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 15, 2023, 
to March 16, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you are a Medicare-certified 
provider. 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 15, 2023, to 
March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diagnostic facet injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary due to your 
condition. The Plan denied your request. The Plan says there is no evidence in the clinical information given 
that there was a consistent relief from the first diagnostic facet joint procedure of at least 80 percent relief of 
primary (index) pain. 
 
The Plan follows Medicare rules. Medicare rules say that the first diagnostic facet joint procedure, there must 
be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee had 80% pain relief. Therefore, the reviewer found that the requested 
injections are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the diagnostic facet injections (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 11, 2023.