Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics i-factor allograft. 
 
You asked the Plan to pre-approve i-factor allograft. You say that the enrollee's pain is getting worse. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Cerapedics i-factor allograft have 
not been demonstrated. 
 
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 i-factor allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Cerapedics i-factor allograft is experimental in spine 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 i-factor allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Cerapedics i-factor allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 0241U for date of 
service January 2, 2023. 
 
You asked the Plan to pay for the laboratory services billed with code 0241U. You say that you disagree with 
the Plan's denial. 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 laboratory services 
billed with code 0241U have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 0241U for date of service January 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 4, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you are not able to pay and you were 
hospitalized when you reached the hospital. You also say that you did not have choice in ambulance because 
you were not able to walk. The Plan denied your request. The Plan says this is a non-covered service.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for ambulance 
services provided on December 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9367 billed for date of service May 27, 
2022, to June 2, 2022. 
 
You asked the Plan to pay for procedure code S9367. You say that this claim should be paid as in-network. The 
Plan denied your request. The Plan says the billed code is 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 code S9367 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9367 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9367 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9367 billed for date of service May 27, 2022, to June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 58712, 38570, and 38900 for billed date of 
service November 4, 2022. 
 
You asked the Plan to pay for procedure codes 58712, 38570, and 38900. You say that you disagree with the 
Plan's denial. 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 January 3, 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 procedure codes 58712, 38570, and 38900 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 58712, 38570, 
and 38900 for billed date of service November 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of neurostimulator electrode array, 
sacral nerve. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show why a full open exposure of the sacrum for direct visualization 
of lead placement is necessary rather than the standard percutaneous approach. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not show why a full open exposure of the sacrum for direct visualization of lead 
placement is necessary rather than the standard, and less-invasive, percutaneous approach. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve open implantation of neurostimulator electrode array, sacral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara System (E1399). 
 
You asked the Plan to pre-approve a Volara System. You say that Intrapulmonary Percussive Ventilation (IPV) 
devices are not approved by Medicare for use in the home. Additionally, the Volara system for the treatment of 
respiratory disorders, is experimental and investigational because there is insufficient evidence supporting its 
effectiveness. The Plan denied your request. The Plan says this device will greatly improve the enrollee's 
bronchial drainage. 
 
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 a Volara System. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Volara system is not medically necessary. This enrollee had bilateral lung transplantation in 2014 for immotile cilia syndrome and recurrent respiratory infections. The enrollee now has 
stage IV allograft dysfunction and severe bronchiectasis with persistent airway infection. The Volara device 
includes 3 components, positive end expiratory pressure, nebulization of medications, and intra-airway 
oscillation. There is inadequate evidence that this device provides better or equivalent airway clearance than 
other devices, or that it is safe and effective in the treatment of bronchiectasis as an outpatient. Nebulization of 
medications would represent a duplication of services already provided. 
 
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 Volara System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara System (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for procedure code 99217. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says payment for code 99217 is bundled into payment for 
code 99226. 
 
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 99217 is a column II code to column I code 99226 with a modifier indicator of 0. The column II 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 99217 billed for date of service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on August 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99285 is 
not supported by the records provided. Our reviewer found that there was no documentation of medical 
decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99285) provided on August 21, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve Lucentis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Lucentis. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Eylea. The documentation does not support that Eylea would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel rendered on June 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that respiratory pathogen panels with more than 5 
respiratory pathogens performed in the Part B outpatient setting are considered not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than five respiratory pathogens were tested 
with codes 87632, 87633, 0115U, 0202U, 0223U, and 0225U. This testing is denied by Medicare as not 
medically necessary.  
 
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 87586 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on June 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to 
May 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to May 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the premium progressive lens, the polycarbonate lens, 
the anti-reflective coating, and the frames provided on June 8, 2022. 
 
You asked the Plan to pay more for the vision items. You say that you disagree with the processing of this 
claim. The Plan denied your request. The Plan says that the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers vision services up to a $100 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 on this claim. Based on this 
information, we decided that the Plan's rules for coverage of the vision items have not been met. Therefore, we 
decided that the Plan does not have to pay more for the premium progressive lens, the polycarbonate lens, the 
anti-reflective coating, and the frames provided on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0240U) provided on November 28, 2022 
 
You asked the Plan to pay for the laboratory test. You say that this test is supported in the medical record. 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 laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0240U) 
provided on November 28, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 billed for date of service July 14, 
2021. 
 You asked the Plan to pay for procedure code 64494. You say that you have rebilled this claim with a 50 
modifier. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64494 have not been met. 
 
Please note this decision is based solely on the claim submitted with 2 units of this code.  If you have submitted 
a new claim for these services, please contact the Plan directly. Therefore, we decided that the Plan does not 
have to pay for procedure code 64494 billed for date of service July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 3, 
2022, to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was ordered by a network 
physician and was medically necessary. The Plan denied your request. The Plan says the billed code is 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 code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 3, 2022, to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Guardant Reveal genetic test (81479) provided on 
November 4, 2022. 
 
You asked the Plan to pay for a Guardant Reveal genetic test. You say that the services at issue have been 
billed 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 molecular diagnostic laboratory tests must 
undergo an application and technical assessment process through the MolDX contractor. Only approved tests 
will be reimbursed consistent with the effective date of the coverage determination.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Guardant Reveal genetic test have not been met. Specifically, we determined that the Guardant 
Reveal genetic test has not been approved through the MolDX contractor. Therefore, we decided that the Plan 
does not have to pay for a Guardant Reveal genetic test (81479) provided on November 4, 2022.