Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 3, 2023, to 
March 4, 2023. 
 You asked the Plan to pay for the home health services. You say that the required NOA is on file. 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 February 3, 2023. The NOA was not received by the Plan until June 14, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 3, 2023, to March 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for SNF services. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio external upper limb tremor stimulator of 
the wrist. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says additional research is needed to determine if this device provides a benefit of equal or 
greater value than the current recognized methods of treating essential tremor. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Medicare has done its own review of this technology and has decided to not cover this technology at 
this juncture. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Cala Trio external upper limb tremor stimulator of the wrist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer. 
 
You asked the Plan to pre-approve the Vertiflex interspinous spacer. You say that you are in constant pain 
and have a hard time performing everyday activities. The Plan denied your request. The Plan says the 
Vertiflex interspinous spacer is not medically necessary as it does not meet established standard of care 
treatment for spinal stenosis. 
 
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 Vertiflex interspinous spacer. Our 
reviewer says that the requested Vertiflex interspinous spacer is not considered medically reasonable and 
necessary. Our physician reviewer found the Vertiflex interspinous spacer is 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 the Vertiflex interspinous spacer have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vertiflex interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 21, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88177 billed for date of service July 14, 
2023.  
 
You asked the Plan to pay for procedure code 88177. 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 88177 is 6. The MAI value for this code is 3. You billed 12 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 88177 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88177 billed for date of service July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Reactiv8 neurostimulator. 
 
You asked the Plan to pre-approve the Reactiv8 neurostimulator. You say that your disease continues to have a 
considerable negative influence on your quality of life. 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 Reactiv8 neurostimulator. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/investigational. Therefore, the request is deemed not 
medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Reactiv8 neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Reactiv8 neurostimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 26, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting a 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 physical therapy 
provided on April 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 10, 2023, to 
March 10, 2023. 
 You asked the Plan to pay for the home health services. You say that there were some errors that needed to be 
fixed before billing. 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 February 10, 2023. The NOA was not received by the Plan until May 13, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 10, 2023, to March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine tract infection (UTI) culture test panel provided on 
March 24, 2023. 
 
You asked the Plan to pay for the UTI panel. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services should not be unbundled. 
 
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 pay for the UTI panel. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a UTI. The services should not be unbundled. Multiple codes for the same date 
of service were provided and not justified as the correct code including all procedures performed was not 
utilized. Also, it was not clear why Ribonucleic acid (RNA) testing for organisms was performed as the 
standard of care (urinalysis + urine culture) was not contraindicated. Therefore, the enrollee did not meet 
criteria for the services rendered. 
 
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 UTI panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the urine tract infection (UTI) culture test panel provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 13, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that because the diagnoses are for different sites 
and morphology, they can be reported together. 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 C44.42 has an Excludes1 note in relation to C43.61. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the anesthesia services have not been met. Therefore, we decided that the Plan does not have to 
pay for anesthesia services provided on June 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 1, 
2023, and forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the requested continuation 
of inpatient psychiatric care from November 1, 2023, and forward is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for continued inpatient psychiatric care from 
November 1, 2023, and forward.   
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. 
Our reviewer says that the enrollee does not meet criteria for continued inpatient psychiatric care from 
November 1, 2023, and forward.  Our physician reviewer found this enrollee did not appear to require inpatient 
mental health treatment beyond the date in question as she was not a danger to herself or others and does not 
have auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date 
in question. It did not appear that the services were reasonably expected to improve the enrollees condition or 
for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan 
however the entire record is not present. It did appear that the records were supervised and evaluated by a 
physician. She was cooperative/compliant with treatment while not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care from November 1, 2023, and 
forward.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drug, intra-articular steroids. The records do not show that the required drug would be 
contraindicated or less effective; therefore, Zilretta is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Methylpred tablet 4 milligrams (mg). 
 
You asked the Plan to pre-approve the medication. You say that the medical records provided will show proof 
of medical necessity.  The Plan denied your request. The Plan says that the information provided was not 
sufficient to support approval for medical necessity.  
 
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 medication. Our reviewer says that 
the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found methylprednisolone 4 mg tablet is indicated as palliative management of lymphomas in adults, 
per Product Information: methylprednisolone oral tablets, methylprednisolone oral tablets. The use is supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal 
(Micromedex). The documentation supports that the requested drug is safe and effective and otherwise 
reasonable and necessary for this 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 the medication have been met. Therefore, we decided that the Plan has to pre-
approve Methylpred tablet 4 milligrams (mg).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Driveline wound management kit. 
 
You asked the Plan to pre-approve the kit. You say that this type of kit contains all of the necessary items to 
clean the wound sufficiently. The Plan denied your request. The Plan says there are in-network/contracted 
durable medical equipment (DME) suppliers who can provide the requested dressing change kits. 
 
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 kit. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that although this requested brand wound management kit conveniently has all the needed supplies to 
take care of the enrollee's wound, these same supplies can be acquired separately via other brands with an equal 
benefit. There is no other medically necessary indication for using the Driveline brand over others to acquire 
the needed supplies.  
 
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 kit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Driveline wound management kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of a nail bed performed on March 13, 2023. 
 
You asked the Plan to pay for the removal of a nail bed. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the LCA coding criteria are not met for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted for code 11750 must include 
one of the appropriate modifiers. This claim was billed without any modifier, so it is not payable.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the removal of a nail bed have not been met. Therefore, we decided that the Plan does not have to 
pay for the removal of a nail bed performed on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 24, 2022. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed were appropriate. 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 S01.01XA has an Excludes1 note in relation to S00.83XA. This means 
that the two diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for the medical services have not been met. Therefore, we decided that the Plan does not 
have to pay for medical services provided on December 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 25, 2022, billed with 
codes 81225, 81226, 81227,81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 
0031U, 0032U, 81479, 81407, 81406, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records have been attached to 
this appeal. Please have a look at the attachment and reconsider the charges which were previously denied. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 25, 2022, billed with codes 81225, 81226, 81227,81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81355, 81335, 81401, 0031U, 0032U, 81479, 81407, 81406, 81238.