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

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and 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 an office visit provided 
on February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 3, 2023, billed with 
code 77080. 
 
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 this service is not covered when considered 
preventative. 
 
The Plan must follow Medicare rules. Medicare rules say that Bone Mass Measurement (BMM) tests are 
covered when billed with a valid diagnosis code indicating the reason the reason for the test is postmenopausal 
female, vertebral fracture, hyperparathyroidism, or steroid therapy. 
 We looked at 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. This claim was billed with diagnosis code 
Z13.820, which is not a valid diagnosis for the service provided. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on January 3, 2023, billed with code 77080.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc or Supartz FX. The documentation does not support that Orthovisc or Supartz FX would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on January 24, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on December 30, 2022. 
 You asked the Plan to pay for the home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. 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 the home visit 
evaluation provided on December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs to be in the hospital 
following the lumbar surgery. The Plan denied your request. The Plan says an admission following the lumbar 
surgery is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found recent records did not describe any previous health history as unstable or not 
controlled at this time. There was no expectation that the enrollee would require hospital services after the 
lumbar surgery.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided from August 2, 
2022, to December 6, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this is an out-of-network 
appeal. The Plan denied your request. The Plan says the provider you used has opted out of Medicare, so these 
claims cannot be paid. 
 
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 a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services provided from August 2, 2022, to December 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service April 5, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain services are included in the global 
surgery package. 
 
We looked at the file and Medicare rules. Review of the file shows that surgery procedure 20610 was provided 
on the same date of service. Code 20610 has a global surgery value of 00 days. Code J3490 was billed within 
the global surgery period of procedure 20610 without an appropriate modifier. This means code J3490 is not 
separately payable as billed.  Based on this information, we decided that Medicare rules for coverage of code J3490 have not been met. 
Therefore, we decided that the Plan does not have to pay for code J3490 for date of service April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter supplies provided on September 26, 2022. 
 
You asked the Plan to pay for the catheter supplies. You say that you are requesting reconsideration of the 
denied claim. 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 the catheter supplies 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on December 06, 2022, to December 
30, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for acupuncture. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 acupuncture provided on December 06, 2022, to 
December 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on March 08, 
2023. 
 
You asked the Plan to pay for an office visit and related 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 an office visit and 
related services provided on March 08, 2023.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: 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 services are medically necessary for the enrollee 
due to their previous functional status, ability to tolerate therapy and the need for close physician monitoring.  
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on December 20, 
2022. 
 
You asked the Plan to pay for hospital care. You say that these services are supported as billed. The Plan 
denied your request. The Plan says the payment for this service is included in the global surgery payment for 
code 36589, which was provided on December 14, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that a postoperative period of 10 days applies to some 
minor surgeries. If the Field 16 entry is 010, A/B MACs (B) do not allow separate payment for postoperative 
visits or services within 10 days of the surgery that are related to recovery from the procedure. Modifier 24 
reports an unrelated evaluation and management service by the same physician during a postoperative period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital care have not been met. Specifically, this same physician performed procedure code 36589 
on December 14, 2022. This procedure has a 10-day postoperative period. The evaluation and management 
service at issue was not reported with modifier 24 to indicate that it was not related to this previous procedure, 
and both claims were submitted with the same diagnoses, indicating that these services were not unrelated. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided on 
December 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you are requesting an expedited 
reconsideration based on medical necessity. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found your physician has ordered a PET 
scan but actually wishes to order a dopamine transporter (DAT) with single-photon emission computed 
tomography (SPECT) scan which would be approved and appropriate for your clinical symptoms. 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on February 6, 2023. 
 
You asked the Plan to pay for the therapy 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 an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes R26.9 and 
R27.0. Diagnosis code R26.9 has an Excludes1 note and cannot be billed with diagnosis code R27.0. Based on 
this information, we decided that Medicare rules for coverage of the therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the therapy services provided on February 6, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided January 1, 2023, to 
January 26, 2023. 
 
You asked the Plan to pay for the SNF services. You say that the medical records support the SNF stay. The 
Plan denied your request. The Plan says that there is no HIPPA code on the claim for pricing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this claim due to "there is no 
HIPPA code on the claim for pricing". The Medicare rule provided by the Plan to support this denial was 
Chapter 13 of the Medicare Program Integrity Manual. This documentation did not include how this rule 
applies to this case. No explanation was provided to support this denial. No other denial rationale was 
provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
skilled nursing facility (SNF) services provided January 1, 2023, to January 26, 2023.  
 
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: 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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF.  
 
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 that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from June 24, 2022, to July 23, 
2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this claim was not submitted with the appropriate artificial admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving home health 
services in 2021 that will continue in 2022, the home health agency must submit a one-time artificial admission 
date corresponding to the From date of the first period of continuing care in 2022.  
 
We looked at the file and Medicare rules. This NOA was not submitted with an artificial admission date 
corresponding to the From date of the first period of continuing care in 2022. Based on this information, we 
decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the 
Plan does not have to pay for home health care provided from June 24, 2022, to July 23, 2022.