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

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
April 19, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that The services 
should be covered. 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 a home visit for the 
evaluation and management provided on April 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure . You say that the enrollee has tried and failed 
conservative treatment without relief. You say the procedure is medically necessary to solve the enrollee's 
chronic low back pain.  The Plan denied your request. The Plan says the Intracept procedure 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 the Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. This means that the cause of pain is not clear.   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service June 13, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 97598 is bundled into payment for code 11043. 
 
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 97598 
is a column II code to column I code 11043. 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 97598 billed for date of service June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87801, 87481 and 87653 billed for 
date of service November 18, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87801, 87481 and 87653. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says the provided records do not support 
the codes 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 87150 is: Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The definition 
of code 87801 is: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. 
 
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 procedure codes 87150 and 87801. Our reviewer says that 
procedure codes 87150 and 87801 do not meet criteria for payment. Our reviewer found that for code 87150, 
you reported modifier 91, indicating a repeat clinical diagnostic laboratory test; however, the provided 
documentation does not include a repeat test, and therefore code 87150 cannot be verified. Also, procedure 
code 87150 would be inclusive to another procedure billed and approved. For code 87801, you reported 
modifier 91, but the provided documentation does not include a repeat test, and therefore code 87801 cannot be 
verified. Also, procedure code 87801 was reported with 3 units; however, this procedure is a panel test 
including multiple organisms. Only 1 unit of service would be billed for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150 and 87801 have not been met. We also find that 
procedure codes 87481 and 87653 have a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure codes 87481 and 87653 are a statutory exclusion. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87150, 87801, 87481 and 87653 billed for date of service November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation. 
 
You asked the Plan to pre-approve non-emergency transportation. You say that the services are necessary. The 
Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergency transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics i-Factor allograft (20930). 
 
You asked the Plan to pre-approve Cerapedics i-Factor allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of Cerapedics i-Factor allograft in 
the setting of a multi-level cervical fusion procedure have 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 Cerapedics i-Factor allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to corroborate that the requested allograft would be as safe or better than standard autograft procedures. 
There is no compelling rationale presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cerapedics i-Factor allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cerapedics i-Factor allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381), 
and unspecified periodontal procedure (D4999). 
 
You asked the Plan to pre-approve D4381 and D4999. You say that this dental work is needed in order to 
monitor the enrollee's condition. The Plan denied your request. The Plan says the denied services are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
localized delivery of antimicrobial agents (D4381), and unspecified periodontal procedure (D4999).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of bevacizumab is required before alternatives can be considered. 
 
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 Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they were unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional hours of in-home support through Papa 
Pals. 
 
You asked the Plan to pre-approve 60 additional hours of in-home support. You say that the services are 
necessary. The Plan denied your request. The Plan says the benefit is limited to 60 hours per year. Additional 
hours are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 60 additional hours of in-home support have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 60 additional hours of in-home support through Papa Pals.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), attendant control (E2331), and transit option kit (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, attendant control, 
and transit option kit. You say that the enrollee has severe muscle weakness and lack of dexterity of their left 
arm and hands, and moderate to severe lack of dexterity and fine motor skills to their right arm and hand, 
making it necessary that they have the controller module and expandable controller harness. You also say that 
you can remove the attendant control and transit kit. The Plan denied your request. The Plan says an electronic 
connection, expandable controller and expandable controller harness cannot be covered as it is not medically 
necessary to control the three approved power options through the joystick (drive interface). The Plan says an 
attendant control cannot be covered when a user-operated control is requested. The Plan also says that a transit 
option is not intended for use at home and cannot be covered. 
 
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 electronic connection, harness, 
expandable controller, and attendant control. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
sufficient strength and function in their upper extremities to manage standard power drives. Our reviewer also 
found that an attendant control is not medically necessary if the attendant control is in addition to user control. 
 
We looked at this physician's review, the file, and Medicare rules. The requested transit option kit is for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. Based on this information, we decided that Medicare rules for coverage of an electronic 
connection, harness, expandable controller, attendant control, and transit option kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), expandable controller (E2377), attendant control (E2331), and transit option kit (K0108).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic behavioral services provided on January 17, 
2023. 
 
You asked the Plan to pay for therapeutic behavioral services. You say that the services should be covered. 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 therapeutic behavioral 
services provided on January 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on 
November 28, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you disagree with the 
copayment. 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 $100 
copayment for diagnostic colonoscopy. 
 
You have been asked to pay a $100 copayment for diagnostic colonoscopy. This item/service falls within the 
diagnostic colonoscopy 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 diagnostic 
colonoscopy provided on November 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided March 6, 2023 to March 31, 
2023. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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 March 6, 2023. The NOA was not received by the Plan until April 14, 
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 
March 6, 2023 to March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and specialty joystick handle for hand control interface (E2323). 

You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and specialty 
joystick handle for hand control interface. The Plan denied your request. The Plan says although there are three 
approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through a special type of joystick. 
 
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 electronic connection, harness, 
expandable controller, and specialty joystick handle for hand control interface. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has sufficient strength and function in their upper extremities to manage standard 
power drives and does not require a specialty joystick because they have normal function in their left upper 
extremity. Our reviewer also found that the enrollee has reduced strength in their right upper extremity, but has 
5 out of 5 strength in their left upper extremity. 
 
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 electronic connection, harness, expandable controller, and specialty joystick 
handle for hand control interface have not been met. Therefore, we decided that the Plan does not have to pre-
approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), and specialty 
joystick handle for hand control interface (E2323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wellness visit provided on May 19, 
2022. 
 
You asked the Plan to waive the coinsurance for the wellness visit. You say that you were not informed about 
the cost of this visit. 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 40% 
coinsurance for out-of-network annual wellness visits. 
 
You have been asked to pay 40% coinsurance for the wellness visit. This item/service falls within the out-of-
network annual wellness visits 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. The total you owe is $54.74 ($136.85 allowed amount x 40% coinsurance = 
$54.74). Therefore, we decided that the Plan does not have to waive the coinsurance for the wellness visit 
provided on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798-XU billed for date of service January 
16, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that medical records have been submitted. The 
Plan denied your request. The Plan says payment for code 87798 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that the enrollee received a urinary tract infection panel test. In this case, we have confirmed 
that code 87798 is a column II code to column I code 87801. The records do not show that the services 
identified by code 87798 was an unusual non-overlapping service. 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 
87798-XU billed for date of service January 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ambien. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ambien.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture and office visit provided by a chiropractor 
on March 13, 2023. 
 
You asked the Plan to pay for the acupuncture and office visit. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the requested services do not meet Medicare 
criteria. 
  
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the acupuncture and office visit provided by a chiropractor on March 13, 
2023.