Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 11, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you called to see if you needed pre-approval for 
behavioral health coverage and was told you would have to pay at the time of the service and submit a claim 
for reimbursement of 70%. The Plan denied your request. The Plan says an opt-out provider cannot bill us, nor 
can we pay you for these services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program.  Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on January 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service October 25, 
2022. 
 
You asked the Plan to pay for procedure code 11721. You say that the services provided were medically 
necessary and meet all applicable professionally recognized standards of healthcare. You say that the claim 
should be processed for payment. The Plan denied your request. The Plan says payment for code 11721 is 
bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service October 25, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PainTEQ LinQ sacroiliac (SI) joint stabilization 
system procedure (0775T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are appealing the adverse decision 
for the enrollee who is currently suffering from lower back pain originating from the sacroiliac joint. The Plan 
denied your request. The Plan says the provider is not using a titanium triangular implant. This request is 
considered investigational and therefore 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this is considered experimental therapy and therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the PainTEQ LinQ sacroiliac (SI) joint stabilization system procedure (0775T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for PT visits provided from December 15, 2022, 
to December 27, 2022. 
 
You asked the Plan to waive the cost share for PT visits. You say that you feel you should pay for services that 
were done incorrectly and caused you more pain. 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. Your 
contract with the Plan says that there is a $196 deductible which applies to outpatient rehabilitation services.  
 
 
  You have been asked to pay a total cost share of $190.86 for PT visits. The item or service you asked the Plan 
to waive the cost share for falls within the outpatient rehabilitation services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $196 deductible which applies to 
outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time 
PT visits was received from December 15, 2022, to December 27, 2022. Therefore, we decided that the Plan 
does not have to waive the cost share for PT visits provided from December 15, 2022, to December 27, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Avastin injection. 
 
You asked the Plan to pre-approve the Avastin injection. You say that Avastin is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
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 the Avastin injection. Our physician 
reviewer found that the Plan requires a trial of drug Mvasi or Zirabev before they will approve Avastin. The 
submitted records do not contain documentation of trial and failure of Mvasi or Zirabev. The documentation 
does not support that Mvasi or Zirabev would likely be less effective or have adverse effects for the enrollee in 
this case. 
 
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 Avastin injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Avastin injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service January 20, 
2023.  
 
You asked the Plan to pay for procedure code 76642. You say that the clam was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies (K0553, 
K0554) provided on December 13, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not 
meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM and supplies. Our reviewer says 
that the items are not medically necessary. Our physician reviewer found that in this case, the record indicates 
that the enrollee has diabetes.  The record provided does not indicate that the enrollee is being currently being 
treated with insulin or has problematic hypoglycemia as defined by the Medicare rules.  
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for a continuous glucose monitor (CGM) and supplies (K0553, K0554) provided on 
December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on January 4, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree that all of your 
maximum benefit had been met. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid $923 for services on January 4, 2023, and $327 for services on January 6, 2023, which is 
the annual maximum of $1,250. After the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay more for dental services provided on 
January 4, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 7, 2022, to  
November 29, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that all of the Plan information you received states 
that mental health services are covered. The Plan denied your request. The Plan says this provider is not part of 
the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
January 7, 2022, to November 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 1, 2022, 
to November 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA two times. 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 November 1, 2022, to 
November 22, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, conventional air services, transport, one way (rotary 
wing) and rotary wing air mileage, per statute mile provided on July 20, 2022. 
 
You asked the Plan to pay for the ambulance service, conventional air services, transport, one way (rotary 
wing) and rotary wing air mileage, per statute mile. You say that this service was medically necessary because 
the patient was diagnosed with unspecified intracranial injury without loss of consciousness, initial encounter.  
The Plan denied your request. The Plan says that after reassessing the entire clinical situation, information 
provided at the time of the appeal does not support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 ambulance service, conventional air 
services, transport, one way (rotary wing) and rotary wing air mileage, per statute mile. Our reviewer says that 
the air ambulance services were medically necessary. Our physician reviewer found the enrollee was non-
verbal and withdrew to pain. Vital signs were notable for tachycardia, tachypnea, and hypotension.  
 
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 ambulance service, conventional air services, transport, one way (rotary 
wing) and rotary wing air mileage, per statute mile have been met. Therefore, we decided that the Plan has to pay for ambulance service, conventional air services, transport, one way (rotary wing) and rotary wing air 
mileage, per statute mile provided on July 20, 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 pre-approve the osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (E0747).  
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the enrollee is 90 days with no 
healing on this fracture. You also say that the requested device is necessary for the enrollee.  The Plan denied 
your request. The Plan says the requested device is not 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 osteogenesis stimulator. Our 
physician reviewer found the fracture is in the small navicuiar bone of the foot. It is not a long bone fracture; 
therefore, the enrollee does not meet the Medicare criteria for the requested stimulator. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, other than spinal 
applications (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service September 
14, 2022, to September 20, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that this is a payable code. 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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service September 14, 2022, to September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 17, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 29, 2022, to 
October 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the NOA and final 
claim. 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 September 29, 2022. The NOA was not received by the Plan until January 
2, 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 September 29, 2022, to October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64447 and 64450 billed for date of service 
January 27, 2023. 
 
You asked the Plan to pay for procedure codes 64447 and 64450. You say that these codes are for post 
operative pain management and should be considered separately from the anesthesia for the surgical procedure. 
The Plan denied your request. The Plan says payment for codes 64447 and 64450 are bundled into payment for 
code 01402. 
 
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 
64447 and 64450 are column II codes to column I code 01402. 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 codes 64447 and 64450 billed for 
date of service January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service January 5, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for a consultation to be provided by 
the requested out-of-network provider. 
 
You asked the Plan to pre-approve physician's services for a consultation to be provided by the requested 
out-of-network provider. You say that your doctor recommended this provider to get treatment for your  
Bells Palsy. The Plan denied your request. The Plan says you must receive your care from a network provider 
in most cases. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services for a consultation to be provided by the requested out-of-network provider.