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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve genicular nerve destruction. You say that the enrollee is in severe pain and 
waiting any longer will be a detriment to his health. He has trouble completing daily activities and weakness 
and tingling to his right leg. The enrollee also has trouble sleeping. The procedure is medically necessary. The 
Plan denied your request. The Plan says the records show that the requested procedure is one that is not the 
standard of care. To be reasonable and necessary, an item or service must not be investigational or 
experimental. 
 
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 destruction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve ablation is experimental and investigational for knee pain. 
There is more research needed. 
 
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 destruction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal (81479) provided December 8, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting review of these 
documents and full allowance of the contracted or list price for the Guardant reveal against the enrollees in 
network benefits. The Plan denied your request. The Plan says this service is considered experimental and 
unproven as there is insufficient evidence of its safety and efficacy. 
 
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. Per DEX Diagnostics Exchange Registry, Guardant Reveal is not covered by Medicare. Per National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer, 
Version 2.2023, there is insufficient data to recommend post-surgical circulating tumor deoxyribonucleic acid 
(ctDNA) to estimate risk of recurrence or determine adjuvant therapy.  Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal (81479) provided December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 20, 2023, billed with 
procedure codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 96365-59, 96366-59, and 96521 is intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1-hour, intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure), and refilling and maintenance of portable pump. 
  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the record states that a continuous 
insulin infusion treatment with glucose measurements was performed. There is a more specific code to report 
this procedure. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 20, 2023, billed with procedure codes 
96365-59, 96366-59, and 96521.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
March 31, 2022, to April 6, 2022.  
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee had uncomplicated soft tissue infection without severe sepsis, so 
lower level of care (e.g., outpatient or observation) could have been provided instead of inpatient status 
(greater than two midnight stay should not have been reasonably expected). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 31, 2022, to April 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 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 skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided March 7, 
2023.  
 
You asked the Plan to pay for a pneumatic compression device. You say that the deep vein thrombosis (DVT) 
unit prescribed after the enrollees surgery was at the request of the physician due to medical necessity to 
prevent blood clots and aid in healing at the enrollees home.  The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 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 find that CPT code E0676 is not supported in the medical record. Specifically, the enrollee 
used the equipment in the facility during and/or after surgery. Payment for this service would have been 
included under the facility claim. Payment for this service is the responsibility of the facility or hospital that 
provided the surgery. Pneumatic compression devised are not covered by Medicare unless for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Based on this 
information, we decided that Medicare rules for coverage of a pneumatic compression device have not been 
met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) 
provided March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the variable-height hospital bed (E0255) 
purchased on January 23, 2023, from an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the hospital bed. You say that this vendor had the bed that was 
needed. The enrollee fell out the crank up bed that was provided and the one you purchased works best. 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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for the variable-height 
hospital bed (E0255) purchased on January 23, 2023, from an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Injectafer. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that that the step 
therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan has to pre-approve Injectafer.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87640) provided on February 2, 2023. 
 
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 this code is 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 CPT code. 
 
We find that CPT code 87640 is not supported in the medical record. Specifically, this code is included in code 
87641 which was also billed. Records were not provided to show a distinct and separate service. 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 (87640) provided on February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 12 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 12 months. 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. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 12 months. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with 
average volume assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 a ventilator for 12 months have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a ventilator for 12 months (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services rendered on January 1, 2023, to January 
6, 2023. 
 
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 payable as billed. 
 
The Plan must follow Medicare rules. The rules say that hospice claims billed for revenue code 0942 that 
contain any other services will be returned to the provider. 
 
We looked at the file and Medicare rules. The file shows that the hospice claim was billed with revenue code 
0942 but contained services other than hospice services. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospice services rendered on January 1, 2023, to January 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 9, 2022 to June 
7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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 May 9, 2022 to June 7, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for procedure code 77062. You say that this service 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee wants to go to the rehab facility.  The 
Plan denied your request. The Plan says an IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 3, 2023, to 
March 15, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted on March 4, 
2023. The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was 
correctly denied. The Plan states that although you content that the NOA was submitted, it has not been 
received. 
 
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 NOA was not received by the Plan. As a result, 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 March 3, 
2023, to March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the standard wheelchair (K0001) purchased March 
9, 2023. 
 
You asked the Plan to reimburse you for the wheelchair. You say that you understand your share to be 50% out 
of network. You purchased the wheelchair for $299.00 and would like to receive 50% reimbursement. The Plan 
denied your request. The Plan says the item was purchased from a supplier who does not participate with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the standard wheelchair 
(K0001) purchased March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection billed with code 64418 provided on January 10, 
2023, by an out-of-network (OON) provider.  
 
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 were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the injection billed with code 64418 provided on 
January 10, 2023, by an out-of-network (OON) provider.