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

 
We decided that the Plan does not have to pay for electrocardiographic monitoring services provided on 
February 1, 2023, to February 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for electrocardiographic monitoring services. You say that you were not able to 
request authorization. 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 electrocardiographic monitoring services provided 
on February 1, 2023, to February 2, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that the enrollee has suffered from 
midline low lumbar pain. The Plan denied your request. The Plan says the Via Disc 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 VIA Disc procedure. Our reviewer 
says that the VIA Disc procedure is not medically necessary. Our physician reviewer found that the requested 
VIA Disc procedure is considered an experimental and investigational procedure. 
 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 VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA Disc procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from August 25, 2021, to September 
23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment was adjusted. 
 
The Plan must follow Medicare rules. Medicare rules say that the first 30-day period of care will be classified 
as early, and all subsequent 30-day periods of care in the sequence (2nd or later) will be classified as late. A 30-
day period will not be considered early unless there is a gap of more than 60 days between the end of one 
period of care and the start of another.  
 
We looked at the file and Medicare rules. In this case, the records show that the enrollee had home health 
services from June 13, 2021, to July 1, 2021. As such, it is inappropriate to bill the services at issue as an early 
episode, as there was not a 60-day gap between periods of care. 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 the services provided from August 25, 2021, to September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR) 
(33285). 
 You asked the Plan to pre-approve placement of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria 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 pre-approve placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR) (33285).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 2, 2022, to 
April 2, 2022. 
 You asked the Plan to pay for the home health services. You say that these claims were denied incorrectly. 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 February 2. 2022. The NOA was not received by the Plan until April 4, 
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 home health services provided 
from February 2, 2022, to April 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (66984-55) provided on January 31, 2022. 
 
You asked the Plan to pay for the services. 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 modifier -55 is used where physicians agree on 
the transfer of care during the global period.  
 
We looked at the file and Medicare rules. Modifier -55 is used to indicate a transfer of care.  Modifier -55 
cannot be billed by the same physician for separate services. 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 the services (66984-55) provided on January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding a progression of the body height loss, kyphotic deformity, or a severe impact on your daily activities. 
Additionally, there is magnetic resonance imaging (MRI) corroboration of retropulsion. Moreover, the DEXA 
scan from June 22, 2023, did not corroborate osteoporosis. Therefore, you do not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 25, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99285 is bundled into payment for code 
99223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99285 is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99285 billed for date of service January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) care. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care. The Plan denied your 
request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of IRF care have been met. Supporting 
medical records related to this request were not submitted. The Plan requested supporting records, but none 
were submitted. Without supporting records, we cannot determine whether the enrollee meets criteria for IRF 
care at this time. Please submit supporting medical records to the Plan for review. Therefore, we decided that 
the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography (93312) and duplex scan (93880) 
provided on August 1, 2022. 
 
You asked the Plan to pay for the echocardiography (93312) and duplex scan (93880). You say that the medical 
records should be reviewed. The Plan denied your request. The Plan says procedure codes 93312 and 93880 are 
not supported by the medical records submitted. 
 
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 93312 is echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); including probe placement, image 
acquisition, interpretation and report. The CPT Code Manual definition of code 93880 is duplex scan of 
extracranial arteries; complete bilateral study. 
 
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 echocardiography (93312) and duplex scan (93880). Our 
reviewer says that procedure codes 93312 and 93880 are not supported. Our reviewer found there are no 
procedure notes describing that these tests were performed, results of the tests, or other evidence supporting 
these codes.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of echocardiography (93312) and duplex scan (93880) have not been met. 
Therefore, we decided that the Plan does not have to pay for the echocardiography (93312) and duplex scan 
(93880) provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and electronics for a power 
wheelchair (E2377, E2313, E2311, E2323). 
 
You asked the Plan to pre-approve the expandable controller and electronics. You say that these features are 
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 an expandable controller is covered when medically 
necessary.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller and 
electronics. Our reviewer says that the requested features are not medically necessary. Our physician reviewer 
found records show that the enrollee has adequate upper body strength to manage standard power drives and 
controls. 
 
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 expandable controller and electronics have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller and electronics for a power 
wheelchair (E2377, E2313, E2311, E2323).
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 February 2, 
2022, to February 19, 2022. You asked the Plan to pay for the billed services. You say that the claim was corrected. 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 February 2, 2022. A valid NOA was not received by the Plan until 
December 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 February 2, 2022, to February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional glaucoma screenings. 
 
You asked the Plan to pre-approve ten (10) additional glaucoma screenings. You say that you need additional 
screenings approved because of the gravity of your condition and you are afraid to lose your vision The Plan 
denied your request. The Plan says at least eleven (11) full months must have passed following the month in 
which the last glaucoma screening examination was performed. Your last glaucoma screening occurred on 
April 28 2023. 
 
The Plan must contract covers an annual glaucoma screening.  
 
We looked at the file and the Plans rules. The file shows that the Plan benefit covers an annual glaucoma 
screening and your last glaucoma screening was on April 28, 2023. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional glaucoma screenings.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on December 23, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for a telehealth visit. You say that this should be covered. 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 a telehealth visit provided on December 23, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80323 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 80323. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 80323 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 80323 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 80323 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 80323 billed for date of service November 4, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services (G0300, G0495, Q5001) provided from April 
30, 2022, to May 29, 2022.  
 
You asked the Plan to pay for home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that the services are not medically 
necessary as the enrollee did not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are medically reasonable and necessary. Our physician reviewer found that the provided medical 
records document uncontrolled hypertension, a new medication order (losartan) and knowledge deficits 
regarding dietary sodium intake and the need for monitoring and teaching by a licensed practical nurse 
regarding hypertension signs, symptoms, and treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pay for the home health services (G0300, G0495, Q5001) provided from April 30, 2022, to May 29, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the enrollee must have had a poor response to Retacrit or Procrit therapy for at least 
two consecutive months even with appropriate dose adjustment.  
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically necessary. Our physician reviewer found the requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives 
Retacrit or Procrit. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have been met. Therefore, we decided that the Plan does not have to 
pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for the F2 and F5 genes (81241 and 
81240). 
 
You asked the Plan to pre-approve genetic testing. You say that your doctor says these tests are necessary. The 
Plan denied your request. The Plan says these tests are not medically necessary in this case according to 
Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the F2 and F5 genes is non-covered 
except for pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve genetic testing for the F2 and F5 genes (81241 and 81240).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections, dexamethasone sodium 
phosphate and triamcinolone acetonide. 
 
You asked the Plan to pre-approve the facet joint injections with steroid injections. You say that you need the 
injections for your back to due to the pain you are experiencing. You say that the pain has caused you not to be 
able to do activities if you do not have the medication.  The Plan denied your request. The Plan says the facet 
joint injections with the steroid injections are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 facet joint injections with steroid 
injections. Our reviewer says that the facet joint injections with steroid injections are not medically necessary. 
Our physician reviewer found that the records indicates that the first diagnostic medial branch blocks (L4-5 and 
L5-S1) were on May 9, 2023. However, there was no documentation of the response you had to the medial 
branch blocks. Therefore, the request is not medically necessary because your records do not show if you had 
at least 80% relief of pain with the first injection. Additionally, the requested medications are not FDA-
approved. 
 
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 facet joint injections with steroid injections have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the facet joint injections, dexamethasone sodium 
phosphate and triamcinolone acetonide.