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

 
We decided that the Plan does not have to pay for procedure code Q0092 billed for date of service February 13, 
2023.  
 
You asked the Plan to pay for procedure code Q0092. You say that the claim is billed correctly and should be 
paid. 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 Q0092 is 2. The MAI value for this code is 3. You billed 4 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 Q0092 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code Q0092 billed for date of service February 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you require rehabilitation and help losing weight 
because you are unable to walk on you own. The Plan denied your request. The Plan says the SNF services 
requested do not meet the requirements for approval. 
 
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 clinical documentation shows that the enrollee has had acute clinical or functional 
status change and would require assessment by skilled therapy or nursing. Documentation shows the enrollee 
has met all inpatient therapy goals; Therefore, daily skilled services on an inpatient basis in a SNF are not 
required 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (33340) provided on September 27, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that you have submitted a corrected claim. You 
say that the service was medically necessary. You also say that the claim was filed timely. The Plan denied 
your request. The Plan says the corrected claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient service was not filed until February 22, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the percutaneous transcatheter closure of the left atrial appendage 
with endocardial implant (33340) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be seen by a rehabilitation 
doctor three times a week. The Plan denied your request. The Plan says that the enrollee does not meet the 
Medicare criteria for admission to an Inpatient Rehabilitation Facility.  
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found this enrollees condition is in fact complex and fragile, and there is every reason to expect to participate 
in and benefit from services to include at minimum physical and occupational therapy, nutritionist, physician 
oversight of her wound care and infection surveillance, as well as case manager for careful coordination of any 
additional services that might be needed at home, the requested inpatient rehab facility admission is approved. 
 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (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 pay for the elective vein surgery provided on October 28, 2022. 
 
You asked the Plan to pay for the elective vein surgery. You say that this was an urgent medically necessary 
procedure. 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 elective vein surgery 
provided on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin protection cushion billed with code E2607 for 
November 29, 2022. 
 
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 are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of 
five years. 
 
We looked at the file and Medicare rules. The file shows that the cushion was purchased less than five years 
from the enrollee's previous cushion was purchased and approved by the Plan and was not irreparably 
damaged. Therefore, we decided that the Plan does not have to pay for the skin protection cushion billed with 
code E2607 for November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service March 8, 
2023. 
 
You asked the Plan to pay for procedure code 77062. You say that the claim is billed correctly and should be 
paid. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service March 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from February 11, 2023, to 
February 23, 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 was reported incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the home health services are not supported in the medical record. Specifically, the claim was reported with an occupational therapy CPT code with a physical therapy revenue code. 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 home health services rendered from February 11, 2023, to 
February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain is disabling, affects 
their quality of life on a daily basis and has been long-term duration. You say that the enrollee has failed non-
operative treatment. You also say that this treatment is the only solution. The Plan denied your request. The 
Plan says the requested procedure is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous basivertebral 
nerve (BVN) will be considered medically reasonable and necessary for the treatment of chronic low back pain 
(cLBP) in patients when there is evidence of Type 1 or Type 2 Modic changes on magnetic resonance imaging 
(MRI). 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found there was 
no documentation provided to indicate Modic changes without facet degenerative joint disease or foraminal 
stenosis. The reviewer found that the documentation does not clearly indicate the cause of the enrollee's back 
pain. Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a wheelchair. You say that the enrollee needs a wheelchair to go outdoors 
and to doctor's appointments. The Plan denied your request. The Plan says medical necessity cannot be 
established as there is not enough clinical information on file. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a wheelchair have been met. there is not enough clinical information on file that supports the enrollee's need for a wheelchair.  There is no 
information on if the enrollee's home is wheelchair accessible or if the enrollee has the ability to self-propel a 
manual wheelchair. Also, wheelchairs are not provided strictly for outdoor use. The records show that the Plan 
made multiple attempts to obtain additional clinical records, prescription and letter of medical necessity 
without success. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair 
(K0001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
June 16, 2022. 
 
You asked the Plan to pay for procedure codes 88341 and 88342. The Plan denied your request. The Plan says 
the claim is not payable. 
 
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 88342 
is a column II code to column I code 88188. 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. 
 
We have also confirmed that code 88341 is an add-on code and has not been billed with an appropriate primary 
procedure code. As the primary code is not payable in this case, the add-on code is also not payable. 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 codes 88341 and 88342 billed for date of service June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the personal emergency response system (S5161). 
 
You asked the Plan to pre-approve the personal emergency response system. You say that the enrollee requires 
a life alert system to prevent falls due to their medical condition. The Plan denied your request. The Plan says 
this service is not a covered benefit as telephone alert systems are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the personal emergency response system (S5161).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve Fasenra. You say that Fasenra is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Fasenra. Our reviewer says that Fasenra 
is not medically necessary. Our physician reviewer found Fasenra is FDA indicated as add-on maintenance 
treatment in patients with asthma with an eosinophilic phenotype. In this case, the enrollee has asthma without 
an eosinophilic phenotype. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Fasenra.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be safely discharged home. You require 
IRF services in order to get stronger. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 20, 2022, billed with 
codes 81249, 81272, 81325, 81351, 81404, 81406 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
July 20, 2022, billed with codes 81249, 81272, 81325, 81351, 81404, 81406 and 81408.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 19, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the service 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 laboratory services 
provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each arthrocentesis provided on January 27, 
2023, to February 10, 2023. 
 
You asked the Plan to waive the copayment for each arthrocentesis. You say that you should not have to pay 
for each injection. 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 $15 
copayment for Medicare Part B drug administration. 
 
You have been asked to pay a $15 copayment for each arthrocentesis. This item/service falls within the 
Medicare Part B drug administration 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 
each arthrocentesis provided on January 27, 2023, to February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services provided on March 27, 
2023. 
 
You asked the Plan to pay for the molecular pathology services. You say that this service does not require prior 
authorization. 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 molecular pathology 
services provided on March 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 21, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says this provider 
type is not eligible to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on March 21, 2023.