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

 
We decided that the Plan does not have to pay for home health services billed for date of service May 12, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
been reported without a required G code to represent a visit by the appropriate HH care discipline(s). 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 pay for home health services billed for date of service 
May 12, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat radiofrequency ablation procedures (64635, 64636). 
 
You asked the Plan to pre-approve repeat radiofrequency ablation. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and ADLs as compared to baseline measurement using the same scale. 
 
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 repeat radiofrequency ablation. Our 
reviewer says that repeat radiofrequency ablation is medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has chronic low-back pain due to spondylosis. The enrollee has had 
greater than 50% pain relief for one year from a previous RFA. Since the enrollee has had greater than 50% 
pain relief for more than 6 months, the request meets coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat radiofrequency ablation have been met. Therefore, we decided that the 
Plan has to pre-approve repeat radiofrequency ablation procedures (64635, 64636).  
 
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 the laboratory services provided on August 15, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 31, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on August 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service September 5, 
2023. 
 
You asked the Plan to pay for procedure code 77061. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service September 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0239U billed for date of service August 7, 
2023. 
 You asked the Plan to pay for procedure code 0239U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 0239U is bundled into 
payment for code 0037U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 0239U 
is a column II code to column I code 0037U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 0239U billed for date of service August 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for a nonadjunctive, nonimplanted 
continuous glucose monitor (CGM), includes all supplies and accessories (A4239) provided on June 30, 2023. 
 
You asked the Plan to pre-approve a supply allowance for nonadjunctive, nonimplanted CGM. You say that 
you disagree with the denial and have submitted all documentation and medical records for review. The Plan 
denied your request. The Plan says the records indicate that the enrollee is on metformin, not treated with 
insulin and there is no documentation that orders were placed for the CGM device or supplies. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a supply allowance for nonadjunctive, 
nonimplanted CGM. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the enrollee takes metformin and was seen in December 2022. Coverage criteria for a CGM requires 
insulin use or low blood glucose sugar (BGS). There is no record of low BGS nor of plans to use insulin; 
hence, although the CGM may help this enrollee, coverage criteria are not met. 
 
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 supply allowance for nonadjunctive, nonimplanted CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a supply allowance for a nonadjunctive, 
nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories (A4239) provided on 
June 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on August 02, 
2023. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you should only have a $55 
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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 reduce the 
copayment for an ultrasound provided on August 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services rendered on May 10, 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 medical necessity for assistant at surgery has not been established. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 51715. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck almost 
never requires a physician as a first assistant at surgery. The records do not clearly document the assistant 
surgeon's role during this portion of the operative session and therefore medical necessity for assistant at 
surgery has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for assistant surgeon services rendered on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on July 18, 2023. 
 
You asked the Plan to pay for the physical therapy services. 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 physical therapy 
services provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the eye surgery provided on June 23, 2021. 
 
You asked the Plan to waive the cost share for the eye surgery. You say that you disagree with the cost share. 
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. Your 
contract with the Plan says that there is a $800 deductible which applies to hospital services. Your contract with 
the Plan also clearly says that you must pay 10% coinsurance of the approved amount for hospital services. 
 
 You have been asked to pay $377.91, which is 10% coinsurance of the allowed amount for the eye surgery 
($3,779.05 allowed amount x 10% = $377.91). This item/service falls within the hospital 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. 
 
You have also been asked to pay $221.94 towards your $800 deductible for the eye surgery. You have been 
asked to pay a total of $599.85 ($377.91 coinsurance + $221.94 deductible = $599.85). The service you asked 
the Plan to waive the cost share for falls within the hospital services benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to hospital 
services. This cost sharing is a contractual obligation that had not been met at the time the eye surgery was 
received on June 23, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the 
eye surgery provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 14, 
2023. 
 
You asked the Plan to pay for procedure code 99497. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99497 is bundled into 
payment for code 99223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), a harness (E2313), an 
expandable controller (E2377), a footplate width extension and a footplate connector (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare guidance says the 
upgraded electronics are not medically necessary. The footplate extension is miscoded. The codes used for the 
foot plates do not match the items requested. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has hip pain and obesity. She has 3-3-/5 strength in upper extremities. 
Per Social Security Administration (SSA) 1862 (a)1(A), the requested accessories are not medically necessary 
as the enrollee has adequate strength to manage standard power drives. Per A52504, there is no separate 
billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), a harness (E2313), an expandable controller 
(E2377), a footplate width extension and a footplate connector (K0108x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interlaminar/interspinous stabilization device 
(22867). 
 
You asked the Plan to pre-approve a Coflex device. 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 a Coflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the coflex device is experimental. More research is needed. 
 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 Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex interlaminar/interspinous stabilization device (22867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transport (A0425, A0428) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergency ambulance transport. You say that the enrollee needs 
transportation to his dialysis appointments by ambulance due to his left side paralysis. The Plan denied your 
request. The Plan says the enrollee must use network providers to get medical care and services. The services 
requested may be obtained in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
non-emergency ambulance transport (A0425, A0428) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion (22633). 
 
You asked the Plan to pre-approve lumbar fusion. 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 lumbar fusion. 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 documentation of a 6-week trial of physical therapy for back pain. More 
conservative measures needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion (22633).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 24, 2023, billed 
with procedure code 01810-QK. 
 
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 diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If the side is not identified in the 
medical record, assign the code for the unspecified side.   
We looked at the file and Medicare rules. We have verified that the claim has not been reported with an 
appropriate diagnosis code. 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 24, 2023, billed with procedure code 01810-QK.