Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 26, 2022, billed with 
codes 99213-25 and 93971-LT-59. 
 You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for these services is included in payment 
for code 36475. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 99213-25 and 93971-LT-59 are column II codes to column I code 
36475; however, 99213-25 and 93971-LT-59 were billed with a modifier.  
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the medical records provided do not 
include sufficient documentation to validate that these services were significant, separately identifiable services 
from procedure 36475, that was also performed on August 26, 2022. Therefore, the use of a modifier to 
unbundle these services is not allowed. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on August 26, 2022, billed with codes 99213-25 
and 93971-LT-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bio-ice pain relief gel provided on December 2, 2022.  
 
You asked the Plan to pay for the medication. You say that this is medically needed and should be covered.  
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 pay for the bio-ice pain relief gel 
provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on October 31, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for surgical services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 surgical services provided on October 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac injections (27096). 
 
You asked the Plan to pre-approve the sacroiliac injections. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that for sacroiliac joint injections to be covered, records 
must show at least three positive findings with provocative maneuvers. 
 
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 sacroiliac injections. Our reviewer 
says that the requested injections are not medically necessary. Our physician reviewer found coverage criteria 
requires documentation of 3 provocative physical exam signs which are not documented in the record.  
 
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 sacroiliac injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac injections (27096).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is appropriate for the enrollee's specific 
clinical need. The Plan denied your request. The Plan says the clinical value and effectiveness has not been 
demonstrated. 
 
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 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient 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 the CardioMEMS procedure.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollees needs can be met at a 
lower level of care such as a skilled nursing facility, outpatient setting, or home health 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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this provider has been covered in the past. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 an office visit provided on January 13, 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 WATS3D testing (88361, 88312, 88305, 88112) 
provided on October 5, 2022.  
 
You asked the Plan to pay for the WATS3D testing. You say that this testing is recommended in the standard 
of practice guideline of major medical studies. The Plan denied your request. The Plan says the clinical value 
and effectiveness of WATS3D testing for screening, diagnosis or surveillance of cancerous or pre-cancerous 
esophageal lesions 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 pay for the WATS3D testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found that the American Society for Gastrointestinal Endoscopy has made a conditional 
recommendation based on low quality evidence and suggests using WATS-3D in addition to white light 
endoscopy in patients with known or suspected Barrett's esophagus. The available documentation does not 
support that the enrollee in this case has known or suspected Barrett's esophagus.  
 
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 WATS3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS3D testing (88361, 88312, 88305, 88112) provided on October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen cell retaining allograft. 
 
You asked the Plan to pre-approve ViviGen cell retaining allograft. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ViviGen cell retaining allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Vivigenallograft is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ViviGen cell retaining allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ViviGen cell retaining allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95937 and 95861 billed for date of service 
October 11, 2022. 
 
You asked the Plan to pay for procedure code(s) 95937 and 95861. The Plan denied your request. The Plan 
says this code is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95937 and 95861. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95937 and 
95861. Based on this information, we decided that Medicare rules for coverage of procedure code 95937 and 
95861 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
95937 and 95861 billed for date of service October 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services provided from June 1, 2022, through 
June 17, 2022.  
 
You asked the Plan to pay for the hospice services. You say that this should be paid without authorization. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospice services provided from June 1, 2022, through 
June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Guidance UTI testing (87481, 87500, 87511, 87640, 
87653, 87798, 87801) provided on November 11, 2022. 
 
You asked the Plan to pay for  the Guidance UTI testing. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI testing have not been met. 
Therefore, we decided that the Plan does not have to pay for  the Guidance UTI testing (87481, 87500, 87511, 
87640, 87653, 87798, 87801) provided on November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator.  Our physician reviewer found a ventilator is not 
eligible for reimbursement for any of the conditions described in this LCD even though the ventilator 
equipment may have the capability of operating in a bilevel positive airway pressure (BiPAP) (E0470, E0471) 
mode. Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bilevel positive 
airway pressure (BiPAP) therapy for conditions described in the Medicare policy will be denied as not 
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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a recent 
and adequate trial of physical therapy for your knee pain. More conservative measures are needed prior to 
surgery. The TKA is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total knee arthroplasty (TKA).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 25, 2022, to 
November 23, 2022. 
 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 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 October 25, 2022. The NOA was not received by the Plan until December 
29, 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 services 
rendered from October 25, 2022, to November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99232) rendered 
from December 3, 2021, to December 23, 2021. 
 
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 Current Procedural Terminology (CPT) code 99232 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity.  Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 the documentation does not 
sufficiently describe an expanded problem focused history or medical decision-making of moderate complexity 
as the enrollee was stable and the case was uncomplicated.  
 
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 subsequent hospital care (procedure code 99232) rendered from December 3, 2021, to 
December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventative medicine evaluation (99387), office visits 
(99212, 99203), testing services (81003, 3008F, 1126F), and an eye exam (92004, 92015) provided from July 
22, 2022, to July 25, 2022. 
 
You asked the Plan to pay for a preventative medicine evaluation, office visits, testing services, and an eye 
exam. You say that these services should be covered under your Point of Service benefit. The Plan denied your 
request. The Plan says these services were not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that the POS benefit 
requires prior authorization. 
 
We looked at the file and Medicare rules. The services at issue were not authorized. Based on this information, we decided that Medicare rules for coverage of a preventative medicine evaluation, office visits, testing 
services, and an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a 
preventative medicine evaluation (99387), office visits (99212, 99203), testing services (81003, 3008F, 1126F), 
and an eye exam (92004, 92015) provided from July 22, 2022, to July 25, 2022.