Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service December 7, 
2022.  
 
You asked the Plan to pay for procedure code 93355. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93355 is bundled into payment for code 
01926. 
 
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 93355 is a column two code to column one code 01926 with a modifier indicator of 0. The column two code is 
therefore 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 code 93355 billed for date of service December 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87500, 
87653, and 87798 for date of service July 5, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the amplified probe 
technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in 
this case. As such, a single code with one unit of service should be used. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with codes 87481, 87500, 87653, and 87798 for date of 
service July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).  
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 pneumatic compression device. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the patient does not 
appear to have any skin breakdown or ulcers to justify this device. She has a basic pneumatic compression 
device, however, it was not clear in the notes whether the patient uses it consistently or that other required 
actions such as eating a healthy diet and exercising regularly were being performed as required. 
 
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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the cervical collar provided on May 18, 2023. 
 
You asked the Plan to pay for the cervical collar. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for the 
cervical collar provided on May 18, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 24, 2023, billed with 
codes 87481, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the documentation supports medical 
necessity. 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. 
 
The file shows that the enrollee received a urinary tract infection panel test. We looked at the file and Medicare 
rules. This NGS panel was not billed with a single 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 24, 2023, billed with codes 87481, 87640, 87653, 
and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 for date of service July 2, 2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are no supported. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
 
 We find that CPT code 99497 is not supported in the medical record. Specifically, no medical records were 
submitted to verify this code billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99497 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99497 for date of service July 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease or stenosis. The reviewer found that the provided documentation does 
not show a clear cause of the enrollee's 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 thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apidra (J1815). 
 
You asked the Plan to pre-approve Apidra. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Apidra (J1815).   
Benefits for Apidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried many other 
treatments, and none have helped. You also say that the enrollees provider advised that this has worked for 
many other patients. The Plan denied your request. The Plan says this is considered experimental and therefore 
is not covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease or stenosis. The reviewer found that the provided documentation does 
not show a clear cause of the enrollee's 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 thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
April 9, 2023, through April 28, 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 the 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 April 9, 2023, through April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for date of service July 19, 
2023. 
 
You asked the Plan to pay for procedure code 83520. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 In this case, the definition of code 83520 is: Immunoassay for analyte other than infectious agent antibody or 
infectious agent antigen; quantitative, not otherwise specified. 
 
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 procedure code 83520 have been met. 
Specifically, procedure code 83520 is a "not otherwise specified" code. The physician order for the provided 
services does not identify the test(s) to be performed as part of code 83520. Code 83520 cannot be verified. 
Therefore, we decided that the Plan does not have to pay for procedure code 83520 billed for date of service 
July 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq tablets. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rinvoq tablets.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis-3 Omega skin substitute. 
 
You asked the Plan to pre-approve Kerecis-3 Omega. You say that if this is denied the enrollee may require 
further reconstruction surgery. The Plan denied your request. The Plan says this is not medically necessary for 
any indication. 
 
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 Kerecis-3 Omega. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current peer-reviewed medical literature does not support that use of skin substitutes 
has been shown in controlled studies in a Medicare-approved journal to result in sustained long-term health 
benefits in patients undergoing Mohs surgery.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis-3 Omega have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis-3 Omega skin substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for the injection. You say that you are getting the infusion at the 
clinic and it should not be billed as an outpatient hospital visit. 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 $150 
copayment for outpatient hospital services. 
 
You have been asked to pay a $150 copayment for the injection. This item/service falls within the outpatient 
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. Therefore, we decided that the Plan does not have to waive the copayment for the injection 
provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 21, 2023, billed with 
procedure code 99232. 
 
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 this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 27, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on June 21, 
2023, billed with procedure code 99232.
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 have not yet returned to baseline and are unable 
to manage independent living. The Plan denied your request. The Plan says you are back to your functional 
baseline and no longer require skilled nursing needs. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, Euflexxa, Supartz, Durolane, and Gelsyn-3. The records do not show that the required 
drugs would be contraindicated or less effective; therefore, Monovisc is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monovisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 8, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 laboratory services provided on March 8, 
2023, by an out-of-network (OON) provider.