Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the remaining PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or recline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven physical therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 29, 2022, to 
November 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the certification period is correct. 
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 October 29, 2022, to 
November 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 19, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a specialist office visit. You say that you are requesting the claim be reprocessed. 
The Plan denied your request. The Plan says that this service is not covered when provided out-of-network. 
 
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 Plans POS option only applies to routine dental services. 
 
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 a specialist office visit provided on January 19, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service 
December 1, 2022. 
 You asked the Plan to pay for procedure code 81345-GZ. You say that this service was medically necessary. 
The Plan denied your request. The Plan says payment for code 81345-GZ is bundled into payment for code 
0089U. 
 
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 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of 
service December 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on March 7, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a portable chest x-ray. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that this service is not covered when provided out-
of-network. 
 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 Plan's POS option only applies to routine dental services. 
 
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 a portable chest x-ray provided on March 7, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) services.  
 
You asked the Plan to pre-approve IGRT services. You say that the records provided support the need for the 
requested treatment. The Plan denied your request. The Plan says the services in dispute are 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 IGRT services. Our reviewer says that 
IGRT services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is 
approved by the Food and Drug Administration (FDA) for use with ultrasound, though that in and of itself does 
not mean that daily imaging is necessary; but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has 
not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general) is not necessary.  Billing for daily IGRT would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy (IGRT) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from December 22, 
2022, to December 23, 2022. 
 You asked the Plan to pay for the outpatient hospital services. You say that your facility rendered services that 
are covered and reimbursable. The Plan denied your request. The Plan says the Albuterol you billed on this 
claim is not coverable, making payment of the entire Outpatient Prospective Payment System (OPPS) claim not 
possible. You need to remove the claim line for this non-covered drug in order to have the remaining services 
priced. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. You billed this OPPS claim with Albuterol, which is a non-covered self-administered drug.  
Until the claim line related to this non-covered drug is removed, the OPPS payment cannot be calculated.  The 
Plan has advised that you need to submit a corrected claim with this line item removed.  Therefore, we decided 
that the Plan does not have to pay for outpatient hospital services provided from December 22, 2022, to 
December 23, 2022.  
 
Benefits for the Albuterol provided may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and 
the footplate accessories (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and footplate accessories. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
requested items are 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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate strength to manage the standard power drive controls. 
The upgraded electronics are not medically necessary to meet the enrollee's needs. 
 
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 upgraded electronics have not been met. A custom platform and foot plate 
bracket assembly coded as K0108 cannot be used for items that have a specific HCPCS code. The requested 
vertical adjustment assembly is included in the joystick electronics and cannot be requested separately. A foot plate cover is not covered as it does not serve a medical purpose. Therefore, we decided that the Plan does not 
have to pre-approve the upgraded electronics (E2311, E2313, E2377) and the footplate accessories (K0108).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department (ED) services provided on December 
6, 2022. 
 
You asked the Plan to pay for the ED services. You say that you do not have any Medicare certification. The 
Plan denied your request. The Plan says your facility is not a valid Medicare provider and you have provided 
no evidence that you can bill Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that generally, licensed independent freestanding 
emergency departments (EDs) cannot bill Medicare.  However, during the COVID-19 Public Health 
Emergency, these providers can become temporary Medicare providers if they meet certain criteria. 
 
In this case, there is no evidence that your facility meets any of the criteria listed above in order to receive 
Medicare payment.  There is no evidence that your facility is affiliated with a hospital, and you have provided 
no evidence that you have completed the temporary enrollment process to become a Medicare hospital.  As a 
result, payment to your facility cannot be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ED services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency department (ED) services provided on December 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G2067 billed as part of an Opioid Treatment Program 
(OTP) on February 12, 2023. 
 
You asked the Plan to pay for code G2067. You say that you are an accredited OTP provider, so this claim 
should be paid. The Plan denied your request. The Plan says you billed the wrong POS code on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 58 must be billed on 
claims submitted for the G codes describing OTP services. In this case, you billed the OTP services in question 
with POS code 57 instead of 58, as is required. This is the incorrect POS code to use for this claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G2067 have not been met. Therefore, we decided that the Plan does not have to pay for code 
G2067 billed as part of an Opioid Treatment Program (OTP) on February 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 3, 2023, to 
January 5, 2023. 
 You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 323. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from January 3, 2023, to January 5, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87653-XU and 87481-XU billed for date of service 
December 29, 2022. 
 
You asked the Plan to pay for codes 87653-XU and 87481-XU. You say that medical records have been 
provided to support payment. The Plan denied your request. The Plan says codes 87653-XU and 87481-XU are 
not supported in the medical record. These codes are included in code 87801. The medical records do not 
support the use of the XU modifier to allow for separate payment. Please note that codes 87798-XU and 87801 
have been approved and are not at issue. 
 
The Plan follows Medicare rules. Medicare rules say that The XU modifier is used to bypass a National Correct 
Coding Initiative (NCCI) edit to note that a distinct service has occurred. This modifier means that the code 
represents an unusual non-overlapping Service, the use of a service that is distinct because it does not overlap 
usual components of the main service.  
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 codes 87653-XU and 87481-XU. Our 
reviewer says that the use of the XU modifier to allow for separate payment of codes 87653-XU and 87481-XU 
is not supported by the medical record. Our physician reviewer found for code 87801, which includes multiple 
organisms, includes Candida species when performed.  The laboratory report does not include documentation 
to support unusual non-overlapping service, therefore this procedure and modifier cannot be verified as a 
separate service. For code 87653, the code includes multiple organisms, such as Streptococcus group B. The 
laboratory report does not include documentation to support unusual non-overlapping service, therefore this 
procedure and modifier cannot be verified as a separate service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87653-XU and 87481-XU have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 87653-XU and 87481-XU billed for date of service December 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service January 6, 
2023. 
 You asked the Plan to pay for procedure code 11720. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 11720 is bundled into payment for code 11719. 
 
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 11720 
is a column II code to column I code 11719. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11720 billed for date of service January 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services rendered on February 1, 2023. 
 
You asked the Plan to pay for the services. You say that the enrollee can't choose the assistant. The Plan denied 
your request. The Plan says the assistant was not a covered specialty. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services rendered 
on February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and a segmental pneumatic appliance for use with pneumatic compressor, 
full arm (E0668). 
 
You asked the Plan to pre-approve a pneumatic compressor and a full arm segmental pneumatic appliance. 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 a segmented, calibrated gradient pneumatic 
compression device (HCPCS code E0652) is only covered when the individual has unique characteristics 
which prevent them from receiving adequate satisfactory pneumatic compression treatment using a 
nonsegmented device along with a segmented appliance or compression device without manual control of the 
pressure in each chamber. 
 
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 pneumatic compressor and a full arm 
segmental pneumatic appliance. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the review has determined that records did not show documentation of lymphedema in her 
chest and/or abdomen. There is also no documentation of the clinical response to treatment with the pneumatic 
compression device, with before and after measurements of the right upper extremity. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 pneumatic compressor and a full arm segmental pneumatic appliance have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor, segmental 
home model with calibrated gradient pressure (E0652) and a segmental pneumatic appliance for use with 
pneumatic compressor, full arm (E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve the procedure. You say that you had no pain after the procedure was done a 
year ago. The Plan denied your request. The Plan says the genicular radiofrequency ablation procedure 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 the procedure. Our reviewer says that 
the genicular radiofrequency ablation procedure is not medically necessary. Our physician reviewer found that 
the enrollee is not enrolled in a clinical trial. Also, this therapy is the subject of ongoing clinical trials and is 
considered experimental. Therefore, the request is 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular radiofrequency ablation procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the molecular testing (code 81455) provided on January 18, 2023. 
 
You asked the Plan to pay for the testing. You say that the test was requested directly from the treating 
physician. The Plan denied your request. The Plan says that there are no medical records to support the service 
provided. 
 
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. Specifically, the Plan has not provided evidence that they made attempts to 
obtain medical records from the ordering physician. Therefore, we decided that the Plan has to pay for the 
molecular testing (code 81455) provided on January 18, 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.