Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says 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 the home ventilator. Our reviewer says 
that this equipment is not medically necessary. Our physician reviewer found there is no diagnosis of thoracic restrictive disease or neuromuscular disease. This patient may benefit from BiPAP during sleep as an 
outpatient. Medicare does not cover a Ventilator when used in a mode a BiPAP machine can provide. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service October 30, 2022. 
 
You asked the Plan to pay for procedure code 99285. 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 4, 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 code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 for date of service October 
30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing air transport and rotary wing air mileage 
provided on November 26, 2022. 
 You asked the Plan to pay for the rotary wing air transport and rotary wing air mileage. You say that the 
submitted medical records support the air transport met the medical necessity guidelines. The Plan denied your 
request. The Plan says the entire clinical information provided at the time of the appeal does not support criteria 
for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the rotary wing air transport and rotary wing 
air mileage . Our reviewer says that the air ambulance services were not medically necessary. Our physician 
reviewer found there are no records from the sending facility/provider identified for review Therefore, there is 
no evidence explaining why the enrollee medically needed to be transported to a more distance facility. As 
such, the transfer 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 rotary wing air transport and rotary wing air mileage  have not been met. 
Therefore, we decided that the Plan does not have to pay for rotary wing air transport and rotary wing air 
mileage provided on November 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not enough clinical evidence to support the effectiveness of this 
procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, 
per session (99183x20). 
 
You asked the Plan to pre-approve hyperbaric oxygen treatment (HBOT). You say that the enrollee will benefit 
from treatment. The Plan denied your request. The Plan says the records do not show that the enrollee has had 
failure of standard diabetic wound care, because there has been no evaluation or correction of any vascular 
abnormalities or bony debridement and culture-based antibiotics for treatment of infection. Under Medicare, 
the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve hyperbaric oxygen treatment (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the review indicates that the enrollee has a past medical history of type 
2 diabetes mellitus, peripheral vascular disease and a chronic lower extremity ulceration. He had treatment with 
a combination of antibiotics, topical wound care, and debridement over a three-month period of time without 
significant improvement in his wounds. His diabetes has been poorly controlled with a HgbA1c reading of 
10.7% as of May 17, 2023. He also has evidence of peripheral vascular disease as evidenced by abnormal ankle 
brachial indices in both lower extremities measured on March 29, 2023. There has been no indication of 
treatment of any of vascular abnormalities. His provider suspects evidence of chronic osteomyelitis, but there 
has been no surgical debridement with bone culture followed by culture-based antibiotics. The review has 
determined that the enrollee does not meet criteria for approval of HBOT. The requested HBOT is not 
medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen treatment (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, per session 
(99183x20).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc OR Supartz FX is required before alternatives can be 
considered. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 28, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 14, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from non-par providers are not covered under an HMO plan unless preauthorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test provided January 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that your claim for the Decision-Dx Melanoma 
test was denied in error and you are requesting it be reprocessed. The Plan denied your request. The Plan says 
this test is considered an investigational/experimental service and is not covered. 
 
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. 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 DecisionDx-Melanoma test provided January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology billed with code 88305 for February 
24, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the surgical pathology billed with code 88305 for February 24, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 14, 2022, 
to December 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA has been sent and 
accepted. 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 November 14, 2022, to 
December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a platelet rich plasma injection provided on January 5, 2023. 
 
You asked the Plan to pay for the injection. You say that you have received the injection previously and had 
been reimbursed. The Plan denied your request. The Plan says a platelet rich plasma injection is a non-covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection have not been met. Specifically, platelet rich plasma injections for joint conditions are 
not covered. Therefore, we decided that the Plan does not have to pay for a platelet rich plasma injection 
provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care services (99223) provided on October 19, 
2022. 
 
You asked the Plan to pay for initial hospital care services. You say that you have billed the services at issue 
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 the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of initial hospital care services have not been met. Specifically, the case record supports that the 
enrollee was receiving outpatient services on the date of service at issue. However, the services at issue in this 
case have been inappropriately reported with an inpatient POS code. Therefore, we decided that the Plan does 
not have to pay for initial hospital care services (99223) provided on October 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 28, 2022, to 
February 25, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the NOA and would 
like the Plan to consider paying this claim. 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 January 28, 2022. The NOA was not received by the Plan until March 10, 
2022. 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 January 28, 2022, to February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
August 12, 2022, to August 31, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for PCDs have not 
been met. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
from August 12, 2022, to August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cochlear implant (L8619) provided March 25, 2022. 
 
You asked the Plan to pay for the cochlear implant. You say that this is a request for the claim to be 
reconsidered for in-network benefits due. 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 April 30, 2022. 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 the cochlear implant have not been met. 
Therefore, we decided that the Plan does not have to pay for the cochlear implant (L8619) provided March 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88307 billed for date of service January 
17, 2023. 
 You asked the Plan to pay for procedure code(s) 88307. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88307. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88307. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88307 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88307 billed for date of service January 17, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2023, billed 
with codes 81001, 87481, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 21, 2023, billed with codes 81001, 87481, 87640, 87653, and 87798.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 24, 2022, to 
May 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 March 24, 2022, to May 
22, 2022.