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

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) services rendered on 
May 1, 2023, to May 31, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that section A9 of the ESRD claim must be billed 
with the patient's height in centimeters on every claim. 
 
We looked at the file and Medicare rules. The file shows that the incorrect information was input into field A9 
of the billed claim. 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 end-stage renal disease 
(ESRD) services rendered on May 1, 2023, to May 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49999 billed for December 2, 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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 48150 
provided on December 2, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 49999 billed for 
December 2, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of RFA. We decided that the Plan does not have to pre-
approve the third level of RFA.  
 
You asked the Plan to pre-approve 3 levels of RFA.. You say that you have proven the request for 3 levels is 
appropriate and works extremely well for the enrollee. The Plan says that the requested service is not 
reasonable and necessary for the enrollee's condition. 
 
 
  We decided that the Plan has to pre-approve 2 levels of RFA and does not have to pre-approve the third 
level of RFA.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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 3 levels of RFA. Our reviewer says that 
the requested procedure partially meets the requirements for approval. Our physician reviewer found the LCD 
has a utilization limit of 2 levels of RFA per session. This request exceeds that limit. Only 2 levels are deemed 
medically reasonable and necessary. The third level is deemed not medically reasonable and 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 2 levels of RFA have been met. Therefore, we decided that the Plan has to pre-
approve 2 levels of RFA and does not have to pre-approve the third level.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) provided on December 12, 
2022, billed with code 95816. 
 
You asked the Plan to pay for the diagnostic test. You say that medical records submitted support code 95816 
and should be paid. The Plan denied your request. The Plan says the Place of Service (POS) 21 billed allows 
only the professional component (PC) payable. The Plan says that the technical component (TC) of the 
diagnostic test is not payable with the POS billed. 
 
The Plan must follow Medicare rules. Medicare rules say that because the diagnostic test was performed in an 
inpatient hospital (POS 21), only the professional component is payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic test have not been met. The inpatient hospital POS allows for only the professional 
component to be payable; since the technical component (TC) is being billed, without modifier -26 code 95816 
cannot be paid for a hospital inpatient setting. Therefore, we decided that the Plan does not have to pay for 
electroencephalogram (EEG) provided on December 12, 2022, billed with code 95816.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on May 11, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that code J44.9 is a valid diagnosis for oxygen. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J43.9 has an Excludes1 note in relation to J44.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for 
oxygen equipment provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and annual depression screening provided on 
August 10, 2022. 
 
You asked the Plan to pay for an office visit and annual depression screening. You say that you have received 
services before and did not have a cost share. 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 40% 
coinsurance for depression screening and $35 copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay 40% coinsurance and $35 copayment for an office visit and annual depression 
screening. These item/service falls within the depression screening and physician/practitioner services, 
including doctors office visits benefit categories. 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 pay for an office visit and 
annual depression screening provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that you did not know the provider was out of network. 
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 an office visit provided 
on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87798 billed for date of service 
May 1, 2023. 
 You asked the Plan to pay for procedure codes 87502 and 87798. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for code 87502 is bundled into payment for code 87633 
and code 87798 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, we have confirmed that code 87502 
is a column II code to column I code 87633. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, there is no documentation of 
a complete description of infectious agent detection by nucleic acid, not otherwise specified. 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 procedure codes 87502 and 87798 billed for date 
of service May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0950, 
E0954, E0955, E1007, E1012, E1028, E2311, E2313, E2363, E2377, E2607, K0040, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the items are 
necessary. The Plan denied your request. The Plan says the enrollee is living in an SNF. Therefore, the 
requested items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a group 3 power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories 
(E0950, E0954, E0955, E1007, E1012, E1028, E2311, E2313, E2363, E2377, E2607, K0040, K0861).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of the lower extremity arteries. 
 
You asked the Plan to pre-approve a duplex scan of the lower extremity arteries. You say that the duplex scan 
of the lower extremity arteries is medically necessary. The Plan denied your request. The Plan says the 
requested duplex scan of the lower extremity arteries 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 a duplex scan of the lower extremity 
arteries. Our reviewer says that the requested duplex scan of the lower extremity arteries is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not 
provide evidence suggesting that useful or actionable information will be obtained from this study. There is 
documentation that the enrollee has palpable pedal pulses bilaterally. There is no documentation of an abnormal ankle-brachial index (ABI). The study in question is, in general, more useful to follow an arterial 
intervention or potentially used in planning an intervention in a patient with documented arterial disease 
requiring 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 a duplex scan of the lower extremity arteries have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a duplex scan of the lower extremity arteries.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the REXULTI. 
 
You asked the Plan to pre-approve the medication. You say that the drug 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 the REXULTI.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immune globulin intravenous (IVIG) infusion. 
 
You asked the Plan to pre-approve IVIG infusion. 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 follows Medicare rules. Medicare rules say that IVIg is covered when specific criteria is met. 
 
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 IVIG infusion. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in order to approve the requested 
services, records provided need to show the enrollee has either a hypogammaglobulinemia or functional 
deficiency should have a well-documented severe polysaccharide non responsiveness and evidence of recurrent 
infections with a proven requirement for antibiotic therapy. The review has determined that the enrollee does 
not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IVIG infusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve immune globulin intravenous (IVIG) infusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513, 22515). 
 You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
percutaneous kyphoplasty (PKP)) is covered when specific criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
service are not medically necessary. Our physician reviewer found there is no trial of bracing for fracture 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513, 22515).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 9, 2023, to 
March 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely 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 February 9, 2023, to 
March 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for June 14, 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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20610 
provided on June 14, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for 
June 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 26, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely 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 April 26, 2022, to April 
27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for telehealth services on June 07, 2023. 
 
You asked the Plan to pay for telehealth services. You say that you are appealing the denial due to no prior 
authorization. The Plan denied your request. The Plan says that  prior authorization was not obtained by the 
provider or facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not send the correct Evidence of Coverage (EOC). Therefore, we 
decided that the Plan has to pay for telehealth services on June 07, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 19, 2023.