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

 
We decided that the Plan does not have to pay for procedure codes 93609, 93623, 93653, 99152, & 99233 
provided on August 31, 2022 to September 1, 2022. 
 
You asked the Plan to pay for procedure codes 93609, 93623, 93653, 99152, & 99233. You say that these 
services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 93609, 93623, 93653, 99152, 99233 are not supported in the medical record. 
Specifically, codes 93623 and 93609 are add-on codes billed without valid, supported primary codes. An 
evaluation and management note for the date of service at issue was not included to support code 99233. Code 
93653 is included in the 90 day global surgery period for code 33208 which was billed for August 29, 2022. Records do not document the presence of a trained observer to support code 99152. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 93609, 93623, 93653, 99152, & 99233 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93609, 93623, 
93653, 99152, & 99233 provided on August 31, 2022 to September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87506) provided on November 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87506) provided on 
November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and lumbar orthosis (L0642) 
provided on March 13, 2023. 
 
You asked the Plan to pay for the office visit (99204) and lumbar orthosis (L0642). You say that the services 
should be covered. 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 (99204) 
and lumbar orthosis (L0642) provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99140 is considered bundled and not separately payable.  
 
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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology follow up visit provided on 
February 06, 2023. 
 
You asked the Plan to waive the copayment for a dermatology follow up visit. You say that this is a surgical 
follow up and should not have a copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a dermatology follow up visit. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 a dermatology follow up visit provided on February 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-preferred brand diabetic test strips. 
 
You asked the Plan to pre-approve non-preferred brand diabetic test strips. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the medical records received do 
not show that the enrollee has tried a preferred brand test strip or a reason why an exception should be made for 
using a non-preferred brand diabetic test strip. 
 
The Plan must follow Medicare rules. The rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file, the Plan's contract, and Medicare rules. In this case, the Plan has a preferred brand for 
diabetic tests strips covered for enrollee. The file does not show that the enrollee has tried the Plan's preferred 
brand test strip or provided documentation showing why an exception should be made for using a non-
preferred brand diabetic test strip. Therefore, we decided that the Plan does not have to pre-approve non-
preferred brand diabetic test strips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says the 
requested trip exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles. Based on this information, we decided that the Plans rules for coverage of routine transportation 
have not been met. Therefore, we decided that the Plan does not have to pre-approve additional miles for 
routine transportation beyond the Plan's 50-mile limit.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the admission to an IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee's condition is in fact complex and fragile following a rather long admission in the acute 
hospital. There is every reason to expect that he will participate in and benefit from services to include at 
minimum physical therapy, occupational therapy, physician management of his medical conditions, as well as 
case management coordination of any additional needs he may have for a sustainable return home. Discharging 
him to a lower level of care merely increases his likelihood of yet another avoidable readmission to the acute 
hospital. 
 
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 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 medical nutrition therapy services provided on July 29, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee received 12, 15-minute medical nutrition 
therapy services with a registered dietician from April 1, 2022, to June 30, 2022. The 12, 15-minute sessions 
equal the 3 hours that the enrollee was entitled to as clearly stated in the Evidence of Coverage. There is no 
additional benefit left after June 30, 2022 until the next calendar year of 2023. 
 The Plan must contract says the Plan covers 3 hours of one-on-one counseling services during your first year 
that you receive medical nutrition therapy services under Medicare (this includes our Plan, any other Medicare 
Advantage plan, or Original Medicare), and 2 hours each year after that. 
 
We looked at the file and the Plans rules. The file shows that the enrollee received 12, 15-minute medical 
nutrition therapy services with a registered dietician from April 1, 2022, to June 30, 2022. The 12, 15-minute 
sessions equal the 3 hours. Therefore, we decided that the Plan does not have to pay for medical nutrition 
therapy services provided on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Level IV - surgical pathology, gross and microscopic 
examination (88305) provided on March 18, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 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 Level IV - surgical pathology, gross and 
microscopic examination (88305) provided on March 18, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinary tract infection panel provided on November 28, 
2022, and billed with codes 87481 and 87798. 
 
You asked the Plan to pay for urinary tract infection panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of urinary tract infection panel have not been 
met. Therefore, we decided that the Plan does not have to pay for urinary tract infection panel provided on 
November 28, 2022, and billed with codes 87481 and 87798.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that Feraheme is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Feraheme have not been 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 Feraheme. Our reviewer says that 
treatment with Feraheme is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Venofer before they will approve the requested drug. The enrollee has anemia 
secondary to iron deficiency and chronic kidney disease. The requested drug is a new start. The provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternative. The record 
does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's 
preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SI joint) fusion with the LinQ system 
(0775T). 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medical studies haven't proven this service is helpful for the treatment of your health 
problem. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
sacroiliitis pathology. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the sacroiliac 
(SI) joint fusion with the LinQ system, 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint (SI joint) fusion with the LinQ system (0775T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical spine surgery (63081, 22846, 22855). 
 
You asked the Plan to pre-approve cervical spine surgery. 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 cervical spine surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested open removal of 
hardware/assessment of fusion with extension C2-3 anterior cervical discectomy and fusion 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 cervical spine surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cervical spine surgery (63081, 22846, 22855).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee's condition is in fact complex, fragile, and evolving from a rehabilitation prognosis point 
of view. There is every reason to expect that he will participate in and benefit from services to include at 
minimum physical therapy, occupational therapy, speech therapy, physician oversight of his neurological and 
cardiovascular comorbidities, and proactive case manager coordination of his long-term disposition needs. His 
needs simply cannot be met at a lower level of care, and such a disposition would come with a heightened risk 
of otherwise avoidable readmission to the acute hospital. 
 
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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 26, 2022, to 
September 22, 2022. 
 You asked the Plan to pay for the home health services. You say that you were not aware of the timely filing 
policy for the NOA. 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 July 26, 2022. The NOA was not received by the Plan until January 12, 
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 provided 
from July 26, 2022, to September 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on February 
17, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. 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 the psychiatric 
diagnostic evaluation provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Primary Immunodeficiency gene panel 
provided on September 20, 2022, and billed with codes 81400, 81338, 81311, 81270, 81250, 81242, 81241, 
81233, 81223, and 81209. 
 
You asked the Plan to pay for the Comprehensive Primary Immunodeficiency gene panel. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Comprehensive Primary 
Immunodeficiency gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Primary Immunodeficiency gene panel provided on September 20, 2022, and billed with 
codes 81400, 81338, 81311, 81270, 81250, 81242, 81241, 81233, 81223, and 81209.