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

 
We decided that the Plan does not have to pre-approve 12 home health skilled nursing visits, 13 home health 
physical therapy visits, and 36 home health aide visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation does not specify any acute clinical status changes, medication or plan of care changes, 
or complex wounds thus the records do not show that 12 additional home health skilled nursing visits are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or 
to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
 
Additionally, the clinical documentation does not provide a plan of care in which the skilled services of a home 
health aide are reasonable and necessary to the treatment of the patients illness or injury thus 36 additional 
home health aide visits are not medically necessary. 
 
Finally, the clinical documentation provides evidence that all appropriate home health skilled physical therapy 
goals have been met thus the records do not show that 13 additional home health physical therapy visits are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the patient's level of function and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 home health skilled nursing visits, 13 home health physical therapy visits, and 
36 home health aide visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel expenses incurred on December 12, 2022. 
 
You asked the Plan to pay for travel expenses. You say that these expenses have been covered in the past. The 
Plan denied your request. The Plan says you received a transplant more than 18 months before the travel at 
issue, so travel expenses are no longer covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which a Medicare 
Advantage (MA) plan provides transplant services at a more distant location, the MA plan must provide 
reasonable transportation for the enrollee and a companion to the distant facility and provide reasonable 
accommodations for the enrollee and a companion while in the distant location for medical care.   
We looked at the file and Medicare rules. The record does not show that the travel at issue was for transplant 
services. Based on this information, we decided that Medicare rules for coverage of travel expenses have not 
been met. Therefore, we decided that the Plan does not have to pay for travel expenses incurred on December 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 26, 2023, billed with 
codes 81403, 81404, 81405, 81406, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. 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 
May 26, 2023, billed with codes 81403, 81404, 81405, 81406, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy or excision of lymph nodes coded as 38510 and 
the intraoperative identification of sentinel lymph nodes coded as 38900 billed on date of service August 28, 
2023. 
 
You asked the Plan to pay for 38510 and 38900. You say that 38510 and 38900 should be paid as billed 
because they were medically necessary and are supported in the documentation. The Plan denied your request. 
The Plan says 38510 is denied because the number of units billed exceeds the maximum allowed. 38900 is 
denied because it requires an appropriate primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. The rules also say that an add-on code is 
eligible for payment only if it is reported with an appropriate primary procedure performed by the same 
practitioner, with the exception of 99292 in certain circumstances. 
 
We looked at the file and Medicare rules. In this case, the MUE for CPT code 38510 is 1. The MAI value for 
this code is 2. You billed 2 units of this code, exceeding the MUE. We have also confirmed that 38900 is an 
add-on code. As the primary procedure has been denied, 38900 not been billed with an appropriate primary 
procedure code. Based on this information, we decided that Medicare rules for coverage of 38510 and 38900 
have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy or excision of 
lymph nodes coded as 38510 and the intraoperative identification of sentinel lymph nodes coded as 38900 
billed on date of service August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 9, 
2023. 
 
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 August 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (71046), set-up (Q0092), and transport (R0070) 
provided on June 23, 2023. 
 
You asked the Plan to pay for the x-ray (71046), set-up (Q0092), and transport (R0070). You say that the 
service should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the x-ray (71046), set-up 
(Q0092), and transport (R0070) provided on June 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 06, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on July 06, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 05, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on July 05, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve the IRF admission and services. You say that the requested IRF admission is 
medically necessary. The Plan denied your request. The Plan says that the notes do not show that your care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that you have complex care needs that require a coordinated team approach; the notes do not show that you 
must have an intensive therapy program (3 hours a day, at least 5 days a week) to improve self-care 
functioning.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that it is the Plan's responsibility to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. The Plan has not submitted the medical 
records used in their decision to deny coverage. Without medical records, we cannot determine whether the 
enrollee meets Medicare criteria for IRF care. Therefore, the Plan has not shown that its decision to deny 
authorization is medically correct or justified. Therefore, we decided that the Plan has to pre-approve the IRF 
admission and services.  
 
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 waive the copayment for the antigen therapy services provided on 
September 08, 2023. 
 
You asked the Plan to waive the copayment for the antigen therapy services. You say that you disagree with the 
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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the antigen therapy services. This item/service falls within 
the physician/practitioner services, including doctors office visits 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the antigen therapy services provided on September 08, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 02, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on June 02, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. You asked the Plan to pre-approve Hyalgan. 
You say that you do not carry step one agents in the office as buy and bill. You only carry Supartz. The Plan denied your request. The Plan says Hyalgan is covered if at least one of these alternative drugs: Monovisc, 
Orthovisc, or Synvisc/Syvisc-One has been tried.  
 
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 Hyalgan. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the Plan requires a trial of 
Monovisc, Orthovisc, or Synvisc/Syvisc-One before they will approve the requested drug. The enrollee has not 
tried and failed the required drug(s). There is no documentation indicating that the Plan's required drug(s) 
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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches (64624). 
 
You asked the Plan to pre-approve destruction of genicular nerve branches. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is not considered medically 
necessary as this procedure is not considered standard of care for the enrollee's condition. 
 
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 destruction of genicular nerve branches. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found genicular nerve block is considered experimental for knee pain, and 
therefore does not meet the criteria for medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction of genicular nerve branches have not been met. Therefore, we 
decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches 
(64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
August 18, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 pay for the urine polymerase chain reaction (PCR) 
panel rendered on August 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided on July 13, 
2023, to August 09, 2023. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you disagree with the 
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 $420 
copayment for inpatient services. 
 
You have been asked to pay a $420 copayment for inpatient services. This item/service falls within the 
inpatient 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 total amount you are being asked to pay is $1,590 ($195 x 6 days = $1,170). ($420 + $1,170 = 
$1,590). Therefore, we decided that the Plan does not have to waive the copayment for inpatient services 
provided on July 13, 2023, to August 09, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the 
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 $60 
copayment for emergency care. 
 
You have been asked to pay a $60 copayment for emergency care. This item/service falls within the emergency 
care 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. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 
27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit provided on March 21, 2023. 
 
You asked the Plan to pay for the mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the mental health visit 
provided on March 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on August 7, 2023. 
 
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 this does not meet coding standards. 
 
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 code 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the case involves the 
subcutaneous administration of Prolia, presumably for the treatment of osteoporosis, though this is not stated in the records. Nothing in the provided medical records in this case describes special considerations for 
preparation, dosage or disposal, frequent changes in infusion rate, prolonged nursing presence or frequent 
conferring with the physician as is described in the CPT codebook as examples of a highly complex 
administration. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96401 rendered on August 7, 2023.