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

 
We decided that the Plan has to pay for the pain management office visit provided on April 28, 2023. 
 
You asked the Plan to pay for the pain management office visit. You say that you have an authorization for this 
service. The Plan denied your request. The Plan says that the service was not authorized. 
 
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. 
 
The enrollee was referred for the pain management office visit by a contract provider. The file does not show 
that the plan provided notice that the pain management office visit would not be covered. Under Medicare 
rules, this means the pain management office visit is considered approved by the plan. Therefore, we decided 
that the Plan has to pay for the pain management office visit provided on April 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator (E0466).. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There is no documentation to indicate that this enrollee would benefit from nocturnal ventilatory 
support. The enrollee does not have a diagnosis for which Medicare covers a home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections.  
You asked the Plan to pre-approve Botox injections. You say that Botox is medically necessary. The Plan 
denied your request. The Plan says a trial of Myrbetriq and Gemtesa is required before alternatives can be 
considered. 
 
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 Botox injections. Our reviewer says 
that Botox injections are not medically necessary. Our physician reviewer found the records do not show a trial 
of the plan preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0315U) provided on February 27, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the lab services. Our reviewer says that the use of code 
0315U is not supported by the records provided. Our reviewer found that the provider reported date of service 
February 27, 2023, however laboratory report documents "Collected: 05/17/2022; Received: 02/28/2023; 
Reported: 03/03/2023". In this case, the dates of service documented in report do not support date of service 
billed.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (0315U) provided on February 27, 2023.
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 the enrollee needs to work with physical 
and occupational therapy in conjunction with respiratory therapy in order to safely return their baseline. The 
Plan denied your request. The Plan says the records do not show that the enrollee needs continued treatment 
that can only be given in a hospital setting. 
 
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 the enrollee is receiving the appropriate care in the current acute care setting. The 
documentation does not support that LTACH services are medically necessary at this time. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) provided on April 
3, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service 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 the medication assisted treatment (G2067) 
provided on April 3, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 16, 2023, billed 
with procedure codes 96365-59, 96366-59 (2 units), 96521, J1817, and G0108. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 96365-59, 96366-59 (2 units), 96521, J1817, and G0108 
is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, 
intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour, 
refilling and maintenance of portable pump, Insulin for administration through durable medical equipment 
(DME) per 50 units, and diabetes outpatient self-management training services, individual, per 30 minutes.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that codes 96365, 96366, and J1817 are 
not supported as there is a more specific code that should be reported for services provided. Also, although 
medical record includes a physician or for refilling and maintenance or portable pump, documentation does not 
support service was performed (96521). In addition, procedure report documents "Direct counseling for 20 
minutes".  For 30 minutes times codes, are furnished in increments of no less than 30 minutes, face to face, as 
the procedure codes are 30-minute time-based codes. Rounding of time furnished is not allowed for 30-minute 
time-based code. As such code G0108 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 16, 2023, billed with procedure 
codes 96365-59, 96366-59 (2 units), 96521, J1817, and G0108.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume 
assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this has been tried 
and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 03, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. 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 laboratory services 
provided on April 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with 
evaluation and management (EM) code 99223-AI. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided. have not been met. This claim was inappropriately billed with 
place of service 21 as documentation shows the enrollee was registered outpatient observation on this date of 
service. Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 4, 
2023, billed with evaluation and management (EM) code 99223-AI.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services (B4185, B4197, B4220, B4224) 
provided on April 6, 2023 to April 11, 2023. 
 
You asked the Plan to pay for the home infusion services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home infusion services have been 
met. Specifically, the physician order is from 2022 and is not for the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for home infusion services (B4185, B4197, B4220, B4224) provided 
on April 6, 2023 to April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 25, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you only went to see your provider to get a 
referral for a second opinion and you did not ask for nor require a refraction service. You say that the Plan 
should cover the service because of the premiums you pay. The Plan denied your request. The Plan says you 
had a refraction on January 4, 2023 that was paid in full by the Plan. Therefore, you already received one 
refraction service in 2023 and a subsequent refraction is not covered.  
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare. For that reason, the Plan's coverage rules apply in this case. The Plan covers these 
services once every calendar year. 
 
 
 We looked at the file and the Plan's rules. The file shows that you have exceeded the Plans routine vision 
benefit. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on  
April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve the genicular artery embolization. You say that the enrollee has significant 
bilateral knee pain and would be a good candidate for this procedure. The Plan denied your request. The Plan 
says the request 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 selective catheter placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that an embolism of the genicular arteries is considered investigational and 
is not medically necessary for the treatment of chronic knee pain.  
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 genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular artery embolization.
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 admission is the most appropriate discharge 
disposition for the enrollee for continued acute and chronic medical needs. The Plan denied your request. The 
Plan says the enrollee does not meet the requirements. The Plan says that the services needed may be provided 
safely in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry office visit provided on April 
26, 2023. 
 
You asked the Plan to waive the copayment for the podiatry office visit. You say that the Plan provides routine 
podiatry services with a $0 copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for podiatry services. 
 
You have been asked to pay a $30 copayment for the podiatry office visit. This item/service falls within the 
podiatry services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. The record shows this claim was approved and you are responsible for the cost share amount. 
Therefore, we decided that the Plan does not have to waive the copayment for the podiatry office visit provided 
on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 30, 2023, billed with 
procedure codes 96365-59, 96366-59 (2 units), and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 96365-59, 96366-59 (2 units), and 96521 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (96365), 
intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional hour 
(96366), and refilling and maintenance of portable pump (96521). 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that codes 96365 and 96366 are not 
supported as there is a more specific code that should be reported for the services provided. Also, the medical 
record includes a physician order for 96521, however does not include documentation to support procedure was 
performed, and therefore this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 30, 2023, billed with procedure codes 
96365-59, 96366-59 (2 units), and 96521.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 7, 2023. 
 
You asked the Plan to pay for the billed services. You say that the procedure code is billed one time only. The 
Plan denied your request. The Plan says the enrollee was in a skilled nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The records show that the enrollee was in a covered SNF stay at the time 
the lab services were provided. This means that the lab services are not separately payable. 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 lab services provided on February 7, 2023.