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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 19, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says payment for code 81456 is bundled into payment for 
code 81455. 
 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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 1, 
2023.  
 
You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service February 1, 2023.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 28, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that this service was 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on February 8, 2023, billed 
with codes 87652, 87500, 87481, 87900, 87798, 87640 and 87799. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on February 8, 2023, billed with codes 87652, 87500, 87481, 87900, 87798, 87640 and 87799.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula additive (B4101) provided February 17, 
2023, to March 18, 2023. 
 
You asked the Plan to pay for enteral formula additive. You say that the doctor prescribed this because you 
need it for your bowels. The Plan denied your request. The Plan says the code B4101 (additive for Enteral 
Formula e.g., Fiber) is not a covered item under Enteral Formula charges. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pay for are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pay for enteral formula additive (B4101) provided February 17, 2023, to March 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reactiv8, restorative permanent neurostimulator 
placement (64590, 64555, C1767, C1778). 
 
You asked the Plan to pre-approve the Reactiv8 neurostimulator. You say that this request is for permanent 
placement. The Plan denied your request. The Plan says this 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 Reactiv8 neurostimulator. Our 
reviewer says that the requested Reactiv8 neurostimulator is not considered medically reasonable and necessary 
in this case. Our physician reviewer found this is considered experimental and investigational therapy.  
Therefore, the requested Reactiv8 neurostimulator is 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 Reactiv8 neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Reactiv8, restorative permanent neurostimulator placement (64590, 64555, 
C1767, C1778).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker (E0143) to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a walker to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a walker (E0143) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the requirements have 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether the requested authorization for placement of an ILR is medically necessary. 
While the enrollee has a history of palpitations, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 24, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that this is medically necessary treatment.  The Plan 
denied your request. The Plan says this is not billed correctly and cannot be covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
11, 2023, to March 2, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this enrollee's medical necessity 
meets the guidelines that qualify for coverage. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 11, 2023, to March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services performed on December 1, 2022. 
 
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 they are the secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider multiple times to receive the primary Explanation of Benefits (EOB). As the secondary insurer, the 
Plan cannot be held responsible for the services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the various services performed on 
December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are unable to move without losing 
oxygen. You also say that the levels drop tremendously whenever you move, and you have fallen as your 
oxygen levels get low. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH 
services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted with an exacerbation of chronic obstructive pulmonary disease. 
The record indicates that you are improving but still require acute care services before transitioning to a lower 
level of care. Our reviewer found that you continue to receive acute care services, and these have not been 
denied. Our physician reviewer also found that the medical record does not indicate that you require services 
that you are not currently receiving but that would be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for May 17, 2023. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 14, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 88291 billed for May 17, 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 enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary.  
 
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 the enrollee does not require rehabilitation nursing or treatment by multiple 
therapies. Although the enrollee had a functional decline from their baseline level of function and would 
benefit from occupational and physical therapy, they do not require the intensity of therapies provided in acute 
inpatient rehabilitation.  
 
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 services provided from June 11, 2023, to June 
17, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the claim was submitted on the incorrect type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill required for HH services is a 4-
digit alphanumeric code that gives two pieces of information. The first three digits indicate the base type of 
bill. The fourth digit indicates the sequence of this bill in this particular period of care. HHAs must submit HH 
PPS claims with the 4th digit of 9. These claims may be adjusted with code 7 or cancelled with code 8. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim for the services at issue was 
submitted on an incorrect type of bill. Therefore, we decided that the Plan does not have to pay for home health 
services provided from June 11, 2023, to June 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services provided on April 10, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R39.15 has an Excludes1 note in relation to N39.41. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory testing services provided on April 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Krystexxa. 
 
You asked the Plan to pre-approve the drug. You say that Krystexxa is a medication that has been approved by 
the FDA for the treatment of chronic gout in adult patients who have failed to normalize serum uric acid and 
whose symptoms are inadequately controlled with conventional urate-lowering therapy. The Plan denied your 
request. The Plan says Krystexxa is 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 drug. Our reviewer says that 
Krystexxa is not medically necessary. Our physician reviewer found that the requested use of Krystexxa is not 
FDA-approved. Krystexxa is also not supported by one of the major drug compendia or by clinical research. 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Krystexxa.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ilumya (J3245). 
 You asked the Plan to pre-approve Ilumya. You say that Ilumya is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Ilumya have not been met. 
 
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 Ilumya. Our reviewer says that 
treatment with Ilumya is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Enbrel, Humira, Otezla or Skyrizi before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Ilumya (J3245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for massage therapy provided from May 18, 2023, to 
May 30, 2023.  
 
You asked the Plan to reimburse you for the massage therapy. You say that you have pain in your right 
shoulder to your low back, radiating down your right leg and foot. You say that this is a recurring problem for 
several years, which is debilitating and you have been reimbursed for the last several years. The Plan denied 
your request. The Plan says the recurrent massage therapy sessions the enrollee purchased out of network were 
not performed by a licensed physical or occupational therapist and are not a covered benefit and have not been 
authorized by the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to reimburse you for massage therapy provided from May 18, 2023, to 
May 30, 2023.