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

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that one of the 
network providers you were referred to will not see you to do the hip x-ray because they did not perform the 
surgery. You say that you wish to have the hip x-rays and orthopedic follow-up visit at the OON facility where 
your surgery took place. You say that the reason you went OON for the surgery is because the Plan's network 
provider wouldn't do anything. You say that the Plan paid for your OON surgery. The Plan denied your request. 
The Plan says there are numerous orthopedic surgeons in-network that should be able to provide ongoing 
surveillance of the enrollee's hip 2 years post-op. The Plan says that they have confirmed with two in-network 
facilities that the enrollee could establish care with them, and records would be collected from the provider that 
performed the surgery.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found you are not currently receiving any active treatment and/or medical management of your 
condition that makes it medically necessary to continue care with the OON provider as requested. There is 
nothing unique about your condition that makes it medically necessary to continue care with the OON provider.  
Detailed documentation is not evident regarding any follow-up examinations corroborating any increased pain 
or findings suggestive of any hardware complications. You are not currently documented to be undergoing any 
active treatments for the right hip and is requesting a routine imaging study for his post-operative 2-year 
evaluation. The Plan has provided in-network providers that are proficient in post-operative total hip 
arthroplasty revision 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 a continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
September 19, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that these services were reported 
correctly and are supported in the medical record. The Plan denied your request. The Plan says payment for 
codes 88341 and 88342 is bundled into payment for code 88360. 
 
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 codes 
88341 and 88342 are column II codes to column I code 88360. These services have 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 codes 88341 and 88342 billed for 
date of service September 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with palonosetron (J2469). 
 
You asked the Plan to pre-approve palonosetron. You say that palonosetron is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says palonosetron has been prescribed for an off-label, not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 palonosetron. Our reviewer says that 
palonosetron is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of palonosetron is not FDA-approved for the enrollee's diagnosis. Palonosetron is FDA-approved for the prophylaxis of nausea and vomiting related to moderately or highly emetogenic chemotherapy; 
however, the enrollee's anticancer agent, Capecitabine, is classified by the American Society of Clinical 
Oncology as having minimal or low emetogenic potential. Neither is this use supported by one of the major 
drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with palonosetron (J2469).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
14, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test (0012M). You say that this service was medically 
necessary. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.   
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test (0012M) have not been met. Therefore, 
we decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine injection provided on March 10, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that the service 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 Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for Bupivacaine injection provided on March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E1002, E1012, E2374, E1028, E2607, E1028, 
K0108, K0108, K0108, E2311, E2313, and E2377). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee will benefit from the requested power wheelchair with accessories to improve their 
overall quality of life by allowing them to safely leave their apartment independently with a decreased risk for 
falls. The Plan denied your request. The Plan says there is no documentation provided indicating that the 
enrollee meets the requirements for a power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power seating 
system may be covered if certain 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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 3 power wheelchair with power tilt and 
power elevating leg rests is not medically necessary. Our physician reviewer found there is insufficient clinical 
documentation supporting the request for a group 3 power wheelchair versus another power mobility device. 
There is no formal power mobility evaluation provided indicating the enrollee's specific level of function is 
with regards to transfers and performing pressure relief and their daily activities. Our reviewer found that there 
is limited documentation provided regarding the enrollees motor strength and range of motion. Our physician 
reviewer also found that without this information it is not possible to determine if the enrollee requires a group 
3 power wheelchair with the requested power options versus another power mobility device. 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E1002, E1012, 
E2374, E1028, E2607, E1028, K0108, K0108, K0108, E2311, E2313, and E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology procedure level 5 (81404). 
 
You asked the Plan to pre-approve molecular pathology procedure level 5. 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 Molecular Diagnostic Services Program (MolDX) 
will review all new test/assay clinical information to determine if a test meets Medicares reasonable and 
necessary requirement. 
 
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 molecular pathology procedure level 5. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found MolDX 
Technical Assessment, the requested test is not an approved test per review of the MolDX Program website. 
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 molecular pathology procedure level 5 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve molecular pathology procedure level 5 (81404).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission to inpatient behavioral health care. 
 
You asked the Plan to pre-approve an admission to inpatient behavioral health care. The Plan denied your 
request. The Plan says the records do not show that you are a threat to yourself or others, that you have severe 
behavioral problems that interfere with your daily functioning, or that you have a specific condition that is 
likely to improve with this level of care. The Plan also says the service you need can be provided safely in 
other settings.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an admission to inpatient behavioral 
health care. Our reviewer says that you do not meet the Medicare criteria for an inpatient behavioral health care 
admission. Our physician reviewer found it was not expected you would improve in a reasonable period of time 
as you did not have dangerousness to yourself or others, auditory or visual hallucinations, delusions and were 
not showing any behavioral issues. Our reviewer also found that it does not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an admission to inpatient behavioral health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an admission to inpatient behavioral health care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary.  The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found that the health Plans denial should be upheld. The enrollee does not require the 
intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded with procedure codes 83630, 
87338, 87507 and 83993 provided April 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this claim for 
payment. The Plan denied your request. The Plan says the appellant needs to resubmit the clam with the correct 
frequency code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT code 83630, 87338, 87507 and 83993 is not supported in the medical record. 
Specifically, the clam was submitted with the frequency code of "8" which indicates to "void/cancel of prior 
claim". The claim needs to be resubmitted with the correct frequency code. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded with procedure codes 83630, 87338, 87507 
and 83993 provided April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99401 billed for date of service January 24, 
2023.  
 
You asked the Plan to pay for procedure code 99401. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99401 is 0. The MAI value for this code is 3. You billed 1 unit of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99401 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99401 billed for date of service January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara device (E1399). 
 
You asked the Plan to pre-approve a Volara device. You say that the enrollee has a multitude of diagnoses that 
prevent her from adequate airway clearance and impaired ability to cough. The device is medically necessary. 
The Plan denied your request. The Plan says the request for an airway clearance and lung expansion device is 
not reasonable and necessary and may in fact be harmful to the enrollee. 
 
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 Volara device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bronchiectasis, chronic inflammatory demyelinating polyneuropathy, 
pulmonary MAI infection, and hypoxemia. The enrollee is intolerant of high-frequency chest wall 
oscillation. There is no documentation that other airway clearance methods have been tried, such as a flutter 
valve. The Volara device has 3 components: Airway oscillation, positive end expiratory pressure, and 
nebulization. The device has not been studied enough to show benefit in the treatment of 
bronchiectasis. Nebulization would duplicate services already provided. Positive end expiratory pressure is 
unlikely to be of benefit. 
 
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 Volara device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Volara device (E1399).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
25, 2022.  
 You asked the Plan to pay for procedure code 76642. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service September 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 29, 2022, to July 
28, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the NOA timely. 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 May 30, 2022. The NOA was not received by the Plan until October 19, 
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 June 29, 2022, to July 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an ophthalmological consultation and services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an ophthalmological consultation and services. You say that it is very 
difficult for the enrollee to travel to the provider suggested by the Plan. The Plan denied your request. The Plan 
says that rules for coverage for OON care have not been met. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers 
located within reasonable distance and travel time from the enrollees home who can provide advanced (tertiary 
care) ophthalmological consultation and services. Under Medicare rules, this means that contract providers are 
not accessible to the enrollee. Therefore, we decided that the Plan has to pre-approve an ophthalmological 
consultation and services to be provided by an out-of-network (OON) provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A4239 is considered bundled and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4239 has a status indicator of 9 on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service March 1, 2023.