Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TEN Urinary Tract Infection panel and TEN Sexually 
Transmitted Infection Panel provided on July 18, 2022.  
 
You asked the Plan to pay for the TEN Urinary Tract Infection panel and TEN Sexually Transmitted Infection 
Panel. You say that this testing was medically necessary. The Plan denied your request. The Plan says based on 
the enrollee's signs and symptoms, targeted testing is more appropriate given the patient's clinical scenario.  
 
The Plan follows Medicare rules. Medicare rules say that expanded panel testing is only indicated when 
targeted panel testing is not appropriate. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the TEN Urinary Tract Infection panel and 
TEN Sexually Transmitted Infection Panel. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the review of the medical records indicates targeted testing had not been 
performed to determine a possible etiology prior to expanded testing. Based on the enrollee's signs and 
symptoms, targeted testing was more appropriate given the enrollee's clinical scenario. The review has 
determined that the enrollee did not meet the LCD criteria for this testing. 
 
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 TEN Urinary Tract Infection panel and TEN Sexually Transmitted Infection 
Panel have not been met. Therefore, we decided that the Plan does not have to pay for the TEN Urinary Tract 
Infection panel and TEN Sexually Transmitted Infection Panel provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Practitioner services provided on January 27, 2023, billed 
with procedure codes 00813-QZ-P2 and 99100. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says procedure code 00813 was billed with an invalid 
diagnosis, and procedure code 99100 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. The rules also say that 
status Indicator B means that payment for covered services is always bundled into payment for other services 
not specified. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner services provided have not been met. Procedure code 00813 was billed with 
diagnosis codes K52.9 and R19.7 which is a code pair that is subject to an Excludes1 note and should not be 
reported together. Procedure code 99100 has a status indicator B and is not separately payable. Therefore, we 
decided that the Plan does not have to pay for Practitioner services provided on January 27, 2023, billed with 
procedure codes 00813-QZ-P2 and 99100.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 26, 2022, to May 
25, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you submitted the NOA in a 
timely manner. 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 April 26, 2022. The NOA was not received by the Plan until June 1, 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 
April 26, 2022, to May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on September 12, 2022. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of 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 the home visit provided 
on September 12, 2022.
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 the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting on an 
intermittent basis.  
 
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 the enrollee is medically stable and does not need physician's supervision 3 times a 
week in an IRF. There are no nursing needs identified or documented. At the current functional level, the 
enrollee does not need specialized and intensive therapies consisting of at least 3 hours of therapy per day at 
least 5 days per week with multidisciplinary approach in an IRF. Documents do not support the necessity for 
admission to an IRF.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a critical care evaluation and management service (99291) 
provided on March 10, 2023. 
 
You asked the Plan to pay for 99291. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the record does not support a minimum of 30 minutes duration for the service 
performed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not support a duration of 30 to 74 minutes for this service. Based on this information, we decided that Medicare rules for 
coverage of 99291 have not been met. Therefore, we decided that the Plan does not have to pay for a critical 
care evaluation and management service (99291) provided on March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter placement of intravascular stent in the left 
cervical carotid artery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not indicate any high risk for carotid endarterectomy (CEA) or 
enrollment in clinical trials or symptomatic carotid artery stenosis between 50% and 70%. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the appropriateness and medical necessity of carotid PTA and stent placement in this 
individual. The enrollee has 50-69% stenosis in the left common carotid artery. The records fail to indicate that the enrollee is not a suitable candidate for carotid endarterectomy (CEA). Guidelines are clear that such a 
procedure would be authorized only if she were not a candidate for CEA.  As such, this request would not be 
considered medically necessary in this enrollees clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter placement of intravascular stent in the left cervical carotid artery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20985 provided on January 12, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 20985. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was not pre-approved to be performed by an out-of-
network provider and was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 procedure code 20985 provided on January 12, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A6196 and A6212 billed for date of service March 31, 
2023. 
 
You asked the Plan to pay for codes A6196 and A6212. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure codes A6196 and A6212 are not payable as billed. 
 
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 A6196 and A6212 has a status indicator of P on the Physician Fee Schedule. This 
means that procedure codes A6196 and A6212 are bundled/excluded. Based on this information, we decided 
that Medicare rules for coverage of codes A6196 and A6212 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes A6196 and A6212 billed for date of service March 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on January 
06, 2023. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you were left in the 
emergency room waiting area. 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for the ambulance service. This item/service falls within the 
ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
service provided on January 06, 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 12, 2023, to 
February 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You did not provide a specific argument with 
your appeal request. 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 January 12, 2023, to 
February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (63047, 
63048). 
 
You asked the Plan to pre-approve laminectomy, facetectomy and foraminotomy. You say that this is medically 
necessary. The Plan denied your request. The Plan says records do not show that the enrollee has tried and 
failed conservative treatment of at least 3 months, or that the enrollee's symptoms have rapidly progressed. 
 
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 laminectomy, facetectomy and 
foraminotomy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that more conservative measures are needed. There is no 
trial of physical therapy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laminectomy, facetectomy and foraminotomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (63047, 
63048).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional occupational therapy sessions.  
 
You asked the Plan to pre-approve the ten (10) additional occupational therapy sessions. You say that ten (10) 
additional occupational therapy sessions are medically necessary. The Plan denied your request. The Plan says 
the requested ten (10) additional occupational therapy sessions 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 ten (10) additional occupational 
therapy sessions. 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 the additional requested 
therapy is not generally accepted as specific and effective therapy for the enrollees condition beyond what was 
approved by the health Plan. The records do not demonstrate that the unique skills of a professional therapist 
are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollees current condition or to prevent 
or slow further deterioration. The enrollee was independent in grooming, toileting, feeding, stairs, bathing. The 
enrollee is noted to be engaging in home tasks with supervision. The enrollee and the enrollees wife have been 
instructed on how to maintain a structured routine for consistency in daily tasks to improve independence in 
activities of daily living for occupational engagement.  
 
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 ten (10) additional occupational therapy sessions have not been met. 
Therefore, we decided that the Plan does not have to pre-approve ten (10) additional occupational therapy 
sessions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99358 and 99359 billed for date of service 
September 15, 2022. 
 You asked the Plan to pay for procedure codes 99358 and 99359. The Plan denied your request. The Plan says 
payment for codes 99358 and 99359 is bundled into payment for code 90792. 
 
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 
99358 and 99359 are column II codes to column I code 90792. 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 codes 99358 and 99359 billed for 
date of service September 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on January 5, 2023. 
 
You asked the Plan to pay for portable X-ray services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which 
another POS code already exists, providers should use the POS code for that entity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable X-ray services have not been met. Specifically, the services at issue have been reported with POS code 11, indicating an outpatient office setting. The case record does not support that the services at 
issue were rendered in an outpatient office setting. Therefore, we decided that the Plan does not have to pay for 
portable X-ray services provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has had epidural steroid injections in 
the past for their back which provided them with a lot of pain relief. The Plan denied your request. The Plan 
says an epidural steroid injection 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 injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee had an 
epidural steroid injection on April 28, 2023, with substantial relief for two months. However, the LCD criteria 
requires three months of 50% pain relief. 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Restylane. 
 
You asked the Plan to pre-approve Restylane. You say that Restylane is a necessity for your care. The Plan 
denied your request. The Plan says Restylane 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 FDA-
approved 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 Restylane. Our reviewer says that 
treatment with Restylane is not medically reasonable and necessary in this case. Our physician reviewer found 
that you have a diagnosis of hoarseness in the setting of vocal cord atrophy. The FDA has not stated that the 
requested drug is indicated for your condition. The Medicare-approved drug compendia do not contain a 
supportive citation for the use of the requested drug in your clinical situation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Restylane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Restylane.