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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 26, 
2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 21, 2023, to April 05, 
2023. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on March 21, 2023, to April 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; 
genicular nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because based on the medical 
literature this procedure is considered experimental or investigational and has not been proven to be beneficial 
for the enrollee's condition.  
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block 
of the right knee 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including 
imaging guidance, when performed (64454).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 9, 2023, to 
August 7, 2023. 
 
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 a correct Q code. 
 
The Plan follows Medicare rules. The rules say that home health claims must be submitted with a correct Q 
code.  
We reviewed the file and the Medicare rules. We find that the claim was not submitted with a Q code 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 
July 9, 2023, to August 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services provided on September 22, 2023, 
billed with codes 87150, 87481, 87500, 87641, 87653, 87798 and 87801. 
 
You asked the Plan to pay for laboratory testing services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says panel testing should be billed using one 
Current Procedural Terminology (CPT) code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory testing services provided on September 22, 2023, billed with codes 
87150, 87481, 87500, 87641, 87653, 87798 and 87801.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xdemvy (J3490). 
 
You asked the Plan to pre-approve the medication. You say that Xdemvy is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xdemvy (J3490).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3. 
 You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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 the medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the Plan requires a trial of Orthovisc OR Supartz FX before they will approve the requested drug. In this 
case, the patient has not tried and failed one of the required drugs. There is no documentation provided 
indicating that the plans required drugs would likely be less effective and/or likely have adverse effects 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Visco-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 for date of service August 16, 2023. 
 
You asked the Plan to pay for procedure code 99221. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code K52.1, defined as 
toxic gastroenteritis and colitis. This code is not an appropriate primary diagnosis as the code has a Code first 
note indicating to code the underlying condition first. Based on this information, we decided that Medicare 
rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99221 for date of service August 16, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 29, 2021, to June 
30, 2021. 
 
You asked the Plan to pay for the home health services. You say that the enrollee was not on hospice during 
this period. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health services provided from June 29, 2021, to June 
30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
May 30, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0483 are not supported in the medical record. The records provided do 
not include lab results for the billed presumptive and definitive drug testing. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on July 21, 2023. 
 
You asked the Plan to pay for a TENS device. You say that the device at issue was a medical necessity for the 
enrollee. 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 provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a TENS device have been met. 
Specifically, a physician order for the device at issue is not evident in the case record. Therefore, we decided 
that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device (E0730) 
provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is considered to 
be experimental/investigational and not covered by the Plan. 
 
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 intraosseous ablation of the 
basivertebral nerve. 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 intracept 
procedure targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. Medicare 
guidelines consider this type of system unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Intracept device to established surgical 
decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with 
the use of Intracept as an alternative to standard surgical treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional air ambulance mileage provided on July 15, 2023. 
 
You asked the Plan to pay for the additional air ambulance mileage. You say that it was medically necessary 
for transport to a further facility as it was better equipped to handle the patient's medical status. The Plan 
denied your request. The Plan says mileage beyond the closest available facility cannot be billed to Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that only local transportation by ambulance is covered, 
and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is 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 pay for the additional air ambulance mileage. Our 
reviewer says that the service was not medically necessary. Our physician reviewer found the air transport was 
not sufficiently supported as there was evidence of a closer appropriate facility less than 37 miles from the 
sending hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional air ambulance mileage have not been met. Therefore, we decided 
that the Plan does not have to pay for additional air ambulance mileage provided on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services provided on 
September 12, 2023. 
 
You asked the Plan to waive the copayment for the ophthalmological services. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for vision care. 
 
You have been asked to pay a $35 copayment for the ophthalmological services. This item/service falls within 
the vision care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmological 
services provided on September 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and a segmental 
pneumatic appliance for use with a pneumatic compressor, full arm (E0668) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and a garment. You say that the enrollee 
needs the pump at home to avoid hospital stays. The Plan denied your request. The Plan says the enrollee must 
use network providers to get medical care and services. 
 
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 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. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device and a segmental pneumatic appliance for use with a pneumatic compressor, 
full arm (E0668) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on July 27, 2023. 
 
You asked the Plan to pay for the cataract surgery. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the cataract surgery 
provided on July 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on May 
04, 2023, to June 21, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests/Medicare-coveredradiological diagnostic services. 
 
You have been asked to pay a $150 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-coveredradiological diagnostic services 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. However, since the allowed amount is 
less than the standard copayment for on date of services, you only owe $133.84. The total amount you are 
being asked to pay is $433.84 ($150 + $150 + $133.84 = $433.84). Therefore, we decided that the Plan does 
not have to waive the copayment for outpatient diagnostic tests provided on May 04, 2023, to June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87150-59, and 87500-59 billed for 
date of service February 15, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the billed codes are correct and valid. The Plan 
denied your request. The Plan says the billed codes are 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. 
 
The file shows that a urinary tract infection panel was provided. There is no evidence that multiple procedures, 
multiple methodologies, or multiple kits were used in this case. As such, a single code with one unit of service 
should be used. Additionally, the MUE for code 87500 is 1. The MAI value for this code is 3. You billed 2 
units of this code, exceeding the MUE. The documentation does not show that the excess units were provided, 
correctly coded, and medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the billed testing have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87801, 87150-59, and 87500-59 billed for date of service February 15, 2023.