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

 
We decided that the Plan does not have to pre-approve ultrasound guided genicular artery embolization. 
 
You asked the Plan to pre-approve ultrasound guided genicular artery embolization. You say that the requested 
ultrasound guided genicular artery embolization is medically necessary. The Plan denied your request. The 
Plan says ultrasound guided genicular artery embolization in the setting of knee osteoarthritis has not been 
demonstrated in the peer reviewed literature. 
 
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 ultrasound guided genicular artery 
embolization. Our reviewer says that the requested ultrasound guided genicular artery embolization is not 
considered medically reasonable and necessary. Our physician reviewer found that the enrollee was being 
treated for unilateral primary osteoarthritis of the left knee. The enrollee presented with left knee pain that is frequent and is rated at 5/10. There is crepitus on active range of motion. There is decreased motion. The exam 
reveals bony deformity and effusion/swelling. There is decreased left knee range of motion. However, there is 
limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. While the studies are noted to be promising, further 
studies/research is needed to corroborate that geniculate artery embolization is as good as or better than 
standard treatments for knee osteoarthritis. No compelling rationale is presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested ultrasound-
guided genicular artery embolization 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 ultrasound guided genicular artery embolization have not been met. Therefore, 
we decided that the Plan does not have to pre-approve ultrasound guided genicular artery embolization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 1, 2022, to 
December 30, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim was originally denied because 
the charges were non-covered, and then because the NOA was untimely. 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 October 2, 2022. The NOA was not received by the Plan until January 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 provided 
from December 1, 2022, to December 30, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99291, 36556 and 93010. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 99292.  
 
You asked the Plan to pay for practitioner services provided on May 4, 2023, billed with procedure codes 
99292, 99291, 36556, and 93010. You say that that the claim is billed correctly and should be paid. The Plan 
says that payment for code 99292 is bundled into payment of another service. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99291, 36556 and 
93010.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99291, 36556 and 93010.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99292. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We looked at the file, and Medicare rules. We have confirmed that code 99292 is a column II code to column I 
code 36556. This claim has not been billed with an appropriate modifier to bypass the edit. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 99292 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 99292. 
 
 
 
 
 
 
 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the imaging services coded as 70544 performed on March 6, 2023. 
 
You asked the Plan to pay for 70544. You say that 70544 should be covered because records support this 
procedure was ordered and performed. The Plan denied your request. The Plan says that payment for code 
70544 is bundled into payment for code 70551, billed by the same provider on the same date of service. 
 
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. The case file did not include proof that code 70551 was billed for date of service 
March 6, 2023, by the same provider who performed code 70544. Without documentation showing 70551 was 
billed by the same provider for the same date of service, we cannot confirm whether the Plans rationale was 
correct in denying 70544. Therefore, we decided that the Plan has to pay for the imaging services coded as 
70544 performed on March 6, 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 pre-approve chiropractic services at the in-network benefit level to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve OON chiropractic services. You say that you have gotten good results using 
this provider and they should be reimbursed at the in-network level. The Plan denied your request. The Plan 
says OON rates will be covered with this provider 
 
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 pre-approve care from out-of-network providers at the in-network benefit level 
only in cases involving emergencies, out of area urgent care and care that cannot be provided by network 
providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services at the in-network benefit level to be provided by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visit and Part B drugs on May 31, 
2023.  
 
You asked the Plan to waive the cost share for office visit and Part B drugs. You say that you want to appeal 
the amount being charged. 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 20% 
coinsurance for Part B drugs that are administered by a provider. Covered drugs include drugs that usually 
arent self-administered by the patient and are injected or infused while you are getting physician, hospital 
outpatient, or ambulatory surgical center services. You must pay a $45 copayment for specialist visit. Covered 
services include consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $98 
and the allowed amount is $21.78. This is less than the copayment amount. The provider billed in the amount 
of $600 and the allowed amount is $143.50 for the services. $143.50 x 20% = $28.70. For both services it's, 
$21.78 + $28.70 = 50.48. Therefore, results in the total cost sharing amount of $50.48. 
 
You have been asked to pay a $21.78 copayment, which is less than the copayment for office visit and 20% 
coinsurance for Part B drugs. This item/service falls within the physician/practitioner services, including 
doctors office visits and Medicare Part B prescription drugs 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 cost share for office visit and Part B drugs on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs or non-routine service for durable medical 
equipment (upgrades) (K0739), electronic connection (E2311), harness (E2313), and additional items and 
accessories (codes E1007, E2620, E0955, E1028 x6, E1012, E0956 x4, K0108 x2, and E2607). 
 
You asked the Plan to pre-approve the wheelchair upgrades and additional items and accessories. You say that 
multiple sclerosis is a chronic progressive debilitating disease, and the requested power chair is medically 
necessary. You also say that the enrollee is trying to remain in their home with supports, and this power chair 
will aide in being able to stay at home. The Plan denied your request. The Plan says the request for 
modifications to your power wheelchair cannot be approved. 
 
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 wheelchair upgrades and additional 
items and accessories. Our reviewer says that the documentation does not support that the patient meets criteria 
for the upgraded electronics and features. Our physician reviewer found the provided records do not fully 
support that the patient is high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap 
surgery. Records do not document the patient performs bladder self-catheterization and is unable to transfer 
independently or that the patient has increased muscle tone or spasticity to meet criteria for the power tilt 
and/or recline and thus the multiple power option base. Our reviewer found that the provided records do not 
clearly document that the enrollee has such upper extremity weakness that they are unable operate the 
wheelchairs power options with their own switches. Our physician reviewer also found that the provided 
records do not document a significant pelvic or spine deformity to meet criteria for the requested cushion(s).  
 
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 upgrades and additional items and accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve repairs or non-routine service for 
durable medical equipment (upgrades) (K0739), electronic connection (E2311), harness (E2313), and 
additional items and accessories (codes E1007, E2620, E0955, E1028 x6, E1012, E0956 x4, K0108 x2, and 
E2607).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 4, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 15, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 16, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next EZ diabetic test strips. 
 
You asked the Plan to pre-approve diabetic test strips. You say that the requested items are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says only the preferred-brand products listed in the 
EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that 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.  Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME 
products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, 
the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use 
of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic test strips. Therefore, we decided that the Plan does not have to pre-approve Contour Next EZ 
diabetic test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you are requesting an additional 2 miles for a total of 52 miles and your 
benefit only allows 50 miles. The Plan also says you have exceeded your benefit 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 up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 71271, defined as computed tomography, thorax, low 
dose for lung cancer screening, without contrast material(s) performed on April 19, 2023. 
 
You asked the Plan to pay for 71271. You say that 71271 should be covered because it is supported in the 
record, and it was billed with an accurate diagnosis code. The Plan denied your request. The Plan says 71271 is 
denied because it was billed with an inappropriate diagnosis code.  
The Plan must follow Medicare rules. Medicare rules say that claims for LDCT for lung cancer screening billed 
with diagnoses other than Z87.891, F17.210, F17.211, F17.213, F17.218 and F17.219 with dates of service 
after October 1, 2015, will be denied. 
 
We looked at the file and Medicare rules. The documentation shows a diagnosis code of Z12.2, defined as 
encounter for screening for malignant neoplasm of respiratory organs. This diagnosis is not listed as a covered 
diagnosis for LDCT for lung cancer screening. Based on this information, we decided that Medicare rules for 
coverage of 71271 have not been met. Therefore, we decided that the Plan does not have to pay for code 71271, 
defined as computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) 
performed on April 19, 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 prefer to admit to acute rehab because you were 
independent and active before coming to the hospital and want to return to being independent. You are eager to 
participate and complete the required 3 hours of therapy and will not get that in a nursing home. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines.  The Plan 
says that the services needed may be provided safely in a lower level of care.  
 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
March 29, 2023. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you believe you are allowed to 
bill these codes. The Plan denied your request. The Plan says the billed codes are invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 15, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided on 
March 10, 2023. 
 You asked the Plan to pay for the Tempus Liquid Biopsy CGP Panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered because the enrollee 
previously had this test. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has not 
been previously tested with the same test using NGS for the same cancer genetic content. 
 
We looked at the file and Medicare rules. In this case the record shows that the enrollee previously had this test 
in January 2023. Based on this information, we decided that Medicare rules for coverage of the Tempus Liquid 
Biopsy CGP Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus 
Liquid Biopsy CGP Panel (81455) provided on March 10, 2023.