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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes and no 
facet degenerative joint disease (djd) or foraminal stenosis. The cause of the back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental. 
 
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 a genicular nerve block. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this approach to treating knee pain is the subject of ongoing clinical trials and is 
considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99199 billed for dates of service April 11, 2022, and 
July 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that you were referred to the clinic by your internist. 
The Plan denied your request. The Plan says that the services are not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services by a contract provider. The file does show other services by the rendering 
provider were paid on the dates of service at issue. The file does not show that the Plan provided notice that the 
billed services would not be covered. Under Medicare rules, this means the billed services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for procedure code 99199 billed for dates 
of service April 11, 2022, and July 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on December 27, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care services provided on December 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says you have used twenty-six (26) 
non emergent trips. You have exceeded your benefit limit for the year. Additional trips are not covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on November 22, 2022.  
 
You asked the Plan to pay for the home health services. You say that this should be paid. The Plan denied your 
request. The Plan says this was not billed on a valid TOB for home health care. 
 
The Plan must follow Medicare rules. Medicare rules say that valid TOBs for home health services provided 
after January 1, 2022, are limited to 032A, 032D, 0327, 0328, and 0329. 
 
We looked at the file and Medicare rules. This claim was billed with TOB 0323, which is not a valid TOB. 
Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided on 
November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair with multiple 
power options and accessories. 
 
You asked the Plan to pre-approve a replacement wheelchair. You say that the enrollee has a four year old 
Group 3 power wheelchair that no longer meets their needs. You also say that the enrollee is unable to weight 
shift independently and needs meals prepared and served. The Plan denied your request. The Plan says expectant replacement simply based on age is not medically necessary. The Plan also says that the seat 
elevation feature is statutorily not covered.  
 
The Plan follows Medicare rules. Medicare rules say that replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a replacement wheelchair. Our reviewer 
says that a replacement wheelchair is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee's current power wheelchair is four years old. The reviewer also found 
that there is no documentation to support that the current power wheelchair is irreparable. Therefore, the 
reviewer found that the request for a replacement power wheelchair is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement Group 3 power wheelchair with multiple power options and 
accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided from 
January 1, 2021, to January 31, 2021. You asked the Plan to pay for SNF care. You say that these services were necessary and should be paid. The 
Plan denied your request. The Plan says this claim was submitted on a no-pay type of bill; therefore, payment 
cannot be made for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that beneficiaries are assumed to be liable on claims using condition code 21, since these 
claims, sometimes called no-pay bills and having all non-covered charges, are submitted to Medicare to 
obtain a denial that can be passed to subsequent payers. SNF care must also be billed with an appropriate 
PDPM code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Specifically, this claim was submitted on a bill using condition code 
21 (210), which is a no-payment type of bill. In addition, the PDPM code submitted on this claim was 
ZZZZZ, which is not a valid code for SNF payment. Therefore, we decided that the Plan does not have to 
pay for Skilled Nursing Facility (SNF) services provided from January 1, 2021, to January 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits (97110 x 10). 
 
You asked the Plan to pre-approve the therapy services. You say that you still have swelling in both knees and 
ankles.  The Plan denied your request. The Plan says 10 additional physical therapy visits are not medically 
necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have chronic stable knee pain and crepitus. You require a 
repetitive exercise program. Continued input from a skilled therapist is not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten (10) additional physical therapy visits (97110 x 10).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular electrical stimulator and related supplies 
billed for date of service September 23, 2021. 
 
You asked the Plan to pay for the billed services. You say that the treatment is properly indicated. The Plan 
denied your request. The Plan says the clinical effectiveness has not been demonstrated in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that neuromuscular electrical stimulation is only 
covered under certain medical indications. 
 
 We looked at the file and Medicare rules. The records do not show that the services were provided for a 
covered indication. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
electrical stimulator and related supplies billed for date of service September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided from December 13, 2022, to 
December 20, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care services provided from December 13, 
2022, to December 20, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on September 10, 2021. 
 
You asked the Plan to pay for the testing. 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 April 21, 2022. 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 the testing have not been met.  Therefore, we 
decided that the Plan does not have to pay for the testing provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 29, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86078 billed for date of service December 5, 
2022.  
 
You asked the Plan to pay for procedure code 86078. You say that the records support medical necessity. 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 86078 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation did not show that the excess units were provided, correctly 
coded, and medically necessary. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86078 have not been met.  Therefore, we decided that the Plan does not have to pay for 
procedure code 86078 billed for date of service December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 1, 2022, to April 
30, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the NOA required. 
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 March 2, 2022. The NOA was not received by the Plan until December 19, 
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 April 1, 2022, to April 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the procedure is medically necessary for the enrollee. 
The provider ordered the transthoracic echocardiogram to evaluate cardiac function and structure, stress 
echocardiogram to evaluate for coronary artery disease. The Plan denied your request. The Plan says that the 
request for a routine annual echocardiogram to screen for heart disease is not approved. The records show the 
enrollee has no cardiac symptoms and is medically stable from a cardiac standpoint. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a TTE. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case.   Our physician 
reviewer found the enrollee has a history of DM II, HTN, dyslipidemia, PAD S/P Angioplasty of both legs, on 
AS, Plavix, Zarelto, and statins without angina, palpitation, symptoms of heart failure, or claudication. The 
echocardiogram can be justified for evaluation of HTN, if not done recently. Stress echocardiogram can be 
justified in this asymptomatic enrollee with severe PAD, and DM II, for evaluation of severe coronary artery 
disease in this diabetic enrollee with severe PAD and limited mobility due to m=DJD, skeletal symptoms of the 
lower extremities. The enrollee has high 10 years ASCVD risk and already is on ASA, moderate intensity 
statin. The decision is therefore overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE have been met. Therefore, we decided that the Plan has to pre-approve a 
transthoracic echocardiography (TTE) (93306).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet all the requirements for additional treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Synvisc. Our reviewer says that the 
documentation does not support that Synvisc is medically reasonable and necessary. Our physician reviewer 
found that current medical literature indicates that this service is considered reasonable when the enrollee has 
experienced improvement in pain and functional capacity following the previous series of injections and at 
least 6 months has elapsed since the prior series of injections. The last viscosupplementation injection with 
Euflexxa was on May 9, 2023. Therefore, a period of 6 months has not elapsed since the prior series of 
injections. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0269 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code G0269. The Plan denied your request. The Plan says procedure 
code G0269 is considered bundled and not separately payable.  
 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 G0269 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code G0269 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0269 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0269 billed for date of service November 9, 2022.