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

 
We decided that the Plan does not have to pay for the home health services provided from March 10, 2023, to 
April 7, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the Core Based 
Statistical Area/Metropolitan Statistical Area (Cbsa/Msa) Code. 
 
The Plan follows Medicare rules. The rules say that for home health service claims, the Core Based Statistical 
Area/Metropolitan Statistical Area (Cbsa/Msa) Code must be submitted correctly. 
 
We reviewed the file and the Medicare rules. We find that the Core Based Statistical Area/Metropolitan 
Statistical Area (Cbsa/Msa) Code was missing or invalid on the claim submitted. Based on this information, we 
find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from March 10, 2023, to April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
March 30, 2023, through April 19, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on March 30, 2023, through April 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service August 17, 
2023.  
 
You asked the Plan to pay for procedure code A0425. You say that you disagree with the Plan's denial. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.  
 In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 255 units of 
this code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with 
an appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A0425 billed for date of service August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria for IRF admission has not been 
fulfilled.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy in an intensive 
rehabilitation therapy program. Medically necessary care can be provided in a different level of care. There is 
no reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit (99349) provided on July 19, 2023. 
provided on July 19, 2023. 
 
You asked the Plan to pay for a home or residence visit (99349) provided on July 19, 2023.. You say that the 
service at issue was medically necessary and rendered in good faith. 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 a home or residence visit 
(99349) provided on July 19, 2023. provided on July 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve the Intraosseous ablation of the basivertebral nerve. You say that the 
enrollee's primary problem is chronic low back pain due to degenerative disc disease that has resulted in the 
development of vertebrogenic pain identified by degenerative endplate changes frequently known by the 
eponym modic on their magnetic resonance imaging (MRI). The Plan denied your request. The Plan says the 
Intraosseous ablation of the basivertebral nerve 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 Intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the Intraosseous ablation of the basivertebral nerve is not medically 
necessary. Our physician reviewer found that there is no MRI showing only modic changes without facet 
degenerative joint disease, and the cause of pain is not clear. 
 
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 Intraosseous ablation of the basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Intraosseous ablation of the basivertebral 
nerve.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 20, 2023, through 
July 21, 2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration and have 
attached medical records for review. The Plan denied your request. The Plan says the NOA was not received 
timely, and the claim was submitted without a Q code line. 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 June 5, 2023. The NOA was not received by the Plan until July 26, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Also, the claim was submitted without a Q code line, and this is required per Medicare regulations 
and needed for proccing. Therefore, we decided that the Plan does not have to pay for home health services 
provided on July 20, 2023, through July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76881 and J7331 billed for dates of service 
May 15, 2023, and May 22, 2023. 
 You asked the Plan to pay for procedure codes 76881 and J7331. You say that these services were necessary 
and were reported appropriately for payment. The Plan denied your request. The Plan says code 76881 is not 
supported for separate payment, and code J7331 is not fully documented in the records provided. 
 
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 76881 is a column II code to column I code 20611; however, 76881 
was billed with a modifier. In addition, the CPT Code Manual definition of code J7331 is hyaluronan or 
derivative, synojoynt, for intra-articular injection, 1 mg. 
 
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 procedure codes 76881 and J7331. Our reviewer says that 
these services are not supported as billed. Our reviewer found that although code 76881 was billed with 
modifier 59 to bypass the NCCI edit, the medical records provided do not include sufficient documentation to 
validate that code 76881 was a distinct and independent procedure from code 20611 on either of the dates in 
question. Therefore, the use of the 59 modifier, and separate payment of code 76881, cannot be verified in 
either case. In addition, the records provided do not include sufficient documentation, including the name of the 
drug, to support that hyaluronan or derivative, for Synojoynt, for intra-articular injection was administered on 
either of the dates in question for the number of units billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 76881 and J7331 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 76881 and J7331 billed for dates of service May 15, 
2023, and May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement procedures provided on October 20, 
2022, to March 21, 2023, by an OON provider.  
 
You asked the Plan to pay for the nail debridement procedures. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nail debridement procedures provided on 
October 20, 2022, to March 21, 2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, Q5001) provided on 
August 8, 2023, through September 6, 2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. 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 April 10, 2023. The NOA was not received by the Plan until October 5, 
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 (G0151, 
G0152, Q5001) provided on August 8, 2023, through September 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system.  
 
You asked the Plan to pre-approve the sprint PNS system. You say that the enrollee has suffered from chronic 
intractable right lower extremity pain for over six months. You say that despite the enrollee engaging in a 
limited home exercise regimen for over six months, the enrollee has not seen sufficient improvement with their 
pain. The Plan denied your request. The Plan says the sprint PNS system 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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
system is considered experimental for chronic pain and 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 the sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lightweight wheelchair (K0003), provided on August 21, 
2023. 
 
You asked the Plan to pay for the lightweight wheelchair. You say that the cost share is wrong 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 $600 deductible which applies to durable medical equipment (DME) 
and related supplies.  
 
The item or service you asked the Plan to pay for falls within the durable medical equipment (DME) and 
related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $600 deductible which applies to durable medical equipment (DME) and related supplies. This 
cost sharing is a contractual obligation that had not been met at the time the lightweight wheelchair was 
received on August 21, 2023. Therefore, we decided that the Plan does not have to pay for the lightweight 
wheelchair (K0003), provided on August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104), 
surgical placement of implant body (D6010), surgical access to an implant body (D6011), guided tissue 
regeneration (D4266), precision attachment, by report (D5862), and precision attachment (D6950) are excluded 
from this benefit 
 
You asked the Plan to pre-approve bone graft at time of implant placement, surgical placement of implant 
body, surgical access to an implant body, guided tissue regeneration, precision attachment, by report, and 
precision attachment. You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says these services are not a listed benefit of your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
graft at time of implant placement (D6104), surgical placement of implant body (D6010), surgical access to an 
implant body (D6011), guided tissue regeneration (D4266), precision attachment, by report (D5862), and 
precision attachment (D6950) are excluded from this benefit
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were assigned a new provider and were not 
made aware of their network status. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 2, 2023. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 
2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Novabone allograft (20930). 
 
You asked the Plan to pre-approve the Novabone allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 Novabone allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Novabone allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Novabone allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal endoscopy procedure described by code 31231 
performed on May 19, 2023. 
 
You asked the Plan to pay for 31231. You say that 31231 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 31231 is denied because it is not supported in the 
documentation. 
 
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 31231 is nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure). 
 
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 31231. Our reviewer says that 31231 is not supported in the 
documentation. Our reviewer found the procedure report documents "Observations: Passed scope through 
bilateral nasal cavities; Anatomic/Physiological Deviations: Large septal perforation. Dried blood with no 
active bleeding." In this case, procedure report does not include sufficient documentation to support service 
billed. For CPT code 31231, a diagnostic evaluation refers to employing a nasal/sinus endoscope to inspect the 
interior of the nasal cavity and the middle and superior meatus, the turbinates, and the sphenoethmoid recess. 
The procedure report does not include documentation to verify this code criteria. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 31231 have not been met. Therefore, we decided that the Plan does not have to 
pay for the nasal endoscopy procedure described by code 31231 performed on May 19, 2023.