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

 
We decided that the Plan has to pay for the radiology services described by code 70450-26 performed on date 
of service March 13, 2023.  
 
You asked the Plan to pay for 70450-26. You say that 70450-26 should be paid as billed because it is supported 
in the medical record and modifier -26 was appended. The Plan denied your request. The Plan says that 70450-
26 is denied because the total procedure of this code was already billed and paid to another provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the case file does not include a claim image or copy of the original 
denied claim for 70450-26. Without the original claim, we are unable to verify how the services at issue were 
actually billed. As such, we are unable to determine if the services at issue in this case would be eligible for 
reimbursement. Therefore, we decided that the Plan has to pay for the radiology services described by code 
70450-26 performed on date of service March 13, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided on July 1, 2023, 
through July 28th, 2023. 
 
You asked the Plan to waive the copayment for the SNF stay. You said that you should not be charged for days 
after the 21
st
 due to an administration error. The Plan denied your request. The Plan says the cost sharing was 
applied 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 $0 
copayment for days 1-20 of SNF care. You must pay a $95 copayment per day for days 21-100. 
 The record shows you have not been charged for the first 20 days of the SNF stay from July 1, 2023, to July 20, 
2023. You have been asked to pay a $95 copayment per day for the remaining seven days of the SNF stay from 
July 21, 2023, to July 27, 2023. You were not charged for the day you were discharged. You have been asked 
to pay a total of $665 ($95 copayment x 7 days = $665). This item/service falls within the skilled nursing 
facility care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay provided on 
July 1, 2023, through July 28, 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 the enrollee meets the full criteria for an IRF 
admission. The Plan denied your request. The Plan says an IRF admission is not medically necessary, but 
skilled therapies as an outpatient or at a skilled nursing facility may be approved upon request.  
 
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 enrollee's comorbid conditions are at their baseline and they have received 
treatment for influenza. The enrollee requires services, but does not require thrice weekly visits with a 
rehabilitation physician.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDx Prostate IntelliScore (EPI) testing (0005U). 
 
You asked the Plan to pre-approve genetic testing. You say that this denial is seriously jeopardizing the 
enrollee's ability to regain maximum function. The Plan denied your request. The Plan says the requested 
testing does not meet the requirements for approval. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided records in this case do not document a prostate specific antigen (PSA) level of 3 
nanograms per milliliter (ng/ml) or greater as required by the LCD Biomarker Testing for Prostate Cancer 
Diagnosis L37733 for coverage. Provided records document the enrollee's PSA was 1.65 ng/ml on November 
28, 2022, and the "last PSA=1.2" in a note dated December 29, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ExoDx Prostate IntelliScore (EPI) testing (0005U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service October 2, 
2023.  
 
You asked the Plan to pay for procedure code 84480. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 84480 is bundled into payment for code 84481. 
 
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 84480 
is a column two code to column one code 84481 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 84480 billed for date of service October 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for phenylephrine hydrochloride (HCl) provided on June 23, 
2023. 
 
You asked the Plan to pay for phenylephrine HCl. You say that you appealing this denial. The Plan denied your 
request. The Plan says no medical records were submitted to support this claim. 
 
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.  
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 phenylephrine HCl have been met. No 
medical records were submitted to support the charge billed on this claim. The Plan attempted to obtain 
medical records, but none were submitted. Therefore, we decided that the Plan does not have to pay for 
phenylephrine hydrochloride (HCl) provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, captains chair, 
patient weight capacity up to and including 300 pounds (K0823). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested power wheelchair does not meet the 
requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that based on 
the medical records provided, there is inadequate documentation that you have a personal mobility deficit that 
impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and 
bathing in customary locations within the home. There is no documentation that your mobility deficit cannot be 
helped by the use of a walker or manual wheelchair. There is inadequate documentation that you would be able 
to operate this wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair, captains chair, patient weight capacity up to and 
including 300 pounds (K0823).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SI joint RFA. 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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visits (G0318, 99350) provided on March 28, 2023. 
 
You asked the Plan to pay for the home visits (G0318, 99350). You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visits (G0318, 
99350) provided on March 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that 12 additional physical therapy visits are 
needed to target specific issues after shoulder surgery. The Plan denied your request. The Plan says 12 
additional physical therapy visits are not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. You have had instruction in a home 
exercise program and do not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 24, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that you were unable to obtain authorization 
prior to the services being performed. 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 office visit (99214) 
provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance (64454). 
 
You asked the Plan to pre-approve genicular nerve block. You say that you have limited mobility and are really 
counting on this procedure to move and function better. The Plan denied your request. The Plan says the 
records show you have chronic arthritic knee pain. The request 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have bilateral knee pain following bilateral total knee replacement. This is 
considered experimental and investigational therapy and is the subject of ongoing clinical trials. Therefore, the 
request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on April 17, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 looked at the file and Medicare rules. Medicare has determined this test is not medically necessary. 
OmniGraf is not listed as a covered test by the DEX registry. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81479) provided on April 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (code J3490) provided on October 16, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this was a medically necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says this service is included when billed with the global 
surgery period of surgery code 64490 so is not separately paid without an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that intra-operative services that are normally a usual 
and necessary part of a surgical procedure are included in the global surgical package when performed by the 
same physician.  
 
We looked at the file and Medicare rules. This local anesthetic bupivacaine is a usual and necessary part of the 
surgical procedure code 64490 so is not separately paid. Based on this information, we decided that Medicare 
rules for coverage of bupivacaine have not been met. Therefore, we decided that the Plan does not have to pay 
for bupivacaine (code J3490) provided on October 16, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance (eg, proton) imaging (MRI) of the pelvis and 
magnetic resonance (eg, proton) imaging (MRI) of the abdomen billed with codes 72195 and 74181 provided 
on August 25, 2023. 
 
You asked the Plan to pay for the MRI of the pelvis and abdomen. You say that the services were billed 
correctly and should be paid. The Plan denied your request. The Plan says that home health services under a 
plan of care are paid based on a 30-day period of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that there is no evidence that these were home health services or 
provided under a home health plan of care. The Plan didnt request any medical records to verify the denial 
reasoning.  Therefore, we decided that the Plan has to pay for the magnetic resonance (eg, proton) imaging 
(MRI) of the pelvis and magnetic resonance (eg, proton) imaging (MRI) of the abdomen billed with codes 
72195 and 74181 provided on August 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the dermatology office visit and related 
services provided on March 8, 2023. 
 
You asked the Plan to waive the deductible for the dermatology office visit and related services. You say that 
you believe that you are not liable for payment. 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 $750 deductible which applies to out-of-network services. 
 
The services you asked the Plan to waive the deductible for fall within the physician/practitioner services, 
including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the dermatology office visit and related services were 
received on March 8, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
dermatology office visit and related services provided on March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning back cushion (E2615). 
 
You asked the Plan to pre-approve positioning back cushion. You say that this is medically necessary for you. 
The Plan denied your request. The Plan says you do not have a diagnosis for which a positioning back cushion 
may be covered. 
 The Plan must follow Medicare rules. Medicare rules say that a positioning back cushion is only covered for 
enrollees with certain qualifying diagnoses.  
 
We looked at the file and Medicare rules. You do not have a qualifying diagnosis for a positioning back 
cushion. Based on this information, we decided that Medicare rules for coverage of positioning back cushion 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a positioning back 
cushion (E2615).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self- administered drugs from October 5, 2023, through 
October 7, 2023. 
 
You asked the Plan to pay for 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 pay for the self- administered drugs from 
October 5, 2023, through October 7, 2023.  
 
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.