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

 
We decided that the Plan does not have to pay for low frequency, non-contact, non-thermal ultrasound, 
including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per 
day (CPT Code 97610) provided to the enrollee on January 27, 2020. 
 
You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the provided procedure is non-covered given that its efficacy and safety for this 
indication has not been established. 
 
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 pay for the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that low-frequency, non-contact, non-thermal ultrasound is 
beneficial for the enrollee's wounds. A review of the medical literature does not support that low frequency, 
non-contact, non-thermal ultrasound is medically reasonable and necessary for the management of non-
pressure chronic ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for low frequency, non-contact, non-thermal ultrasound, including topical application(s), when 
performed, wound assessment, and instruction(s) for ongoing care, per day (CPT Code 97610) provided to the 
enrollee on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 13, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid order for these tests and some of the test types billed do not match the specimen used 
for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 7, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid order for these tests and some of the test codes billed do not match the specimen type 
reported on the order form. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you had a low blood 
sugar episode and your husband called for an ambulance because he could not wake you up. You say that when 
the ambulance arrived, the responders treated you with an IV and your blood sugar rose within minutes. You 
stated that the responders stayed with you until you were able to move around steadily and then you refused 
ambulance transportation. You say that you were aware of what to watch out for and you had no further 
problems. You asked the Plan to review the situation and reconsider providing coverage for the ambulance 
services. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management
infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies
and equipment (drugs and nursing visits coded separately), per diem (CPT Code S9328) provided to the
enrollee from July 25, 2018 through October 17, 2018.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says this is not payable by Medicare or the Plan. The Plan states to resubmit the claim for
payment with a payable 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.
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The
S codes are used by the Blue Cross/Blue Shield Association (BCBSA) and the Health Insurance Association of
America (HIAA) to report drugs, services, and supplies for which there are no national codes but for which
codes are needed by the private sector to implement policies, programs, or claims processing. They are for the
purpose of meeting the particular needs of the private sector. These codes are also used by the Medicaid
program, but they are not payable by Medicare. Therefore, we decided that the Plan does not have to pay for
home infusion therapy, implanted pump pain management infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem (CPT Code S9328) provided to the enrollee from July 25, 2018 through October 17,
2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 35571) provided to the enrollee on March 31, 2020.
You asked the Plan to pay for the services. You say that according to billing guidelines, a physician does not need to use a modifier when billing with an assistant surgeon. The Plan denied your request. The Plan says the denied code requires an anatomical modifier.
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 35571 is "Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels." We find that CPT code 35571 is not supported in the medical record. Specifically, this code requires an anatomical modifier such as LT, RT, or 50 to specify the nature and location of the denied procedure. 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 pay for surgical services (CPT 35571) provided to the enrollee on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 12, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or the facility. 
 
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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on March 12, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the spinal surgery provided on February 10, 2020. 
 
You asked the Plan to pay for the spinal surgery. You say that the records support the billed services. The Plan 
denied your request. The Plan says that the documentation does not include the actual date of service. Of note, 
the charted date, dictated date, transcribed date, admit date or discharge date, collected date is not sufficient and 
cannot be used to verify the date of service. 
 
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 documentation submitted does not support the Plan's denial rationale. The 
operative note indicates that the enrollee was admitted for the procedure on February 10, 2020 and discharged 
on February 11, 2020. The note documents that dictation took place on February 10, 2020 which could not 
occur until after the surgery was performed. Based on the entirety of the evidence, we find that the 
documentation supports that this surgery was performed on February 10, 2020 which matches the billed date of 
service. Therefore, we decided that the Plan has to pay for the spinal surgery provided on February 10, 2020.  
 
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 care management services (99484) provided on December 2, 2019.
You asked the Plan to pay for the care management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 99484 is care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements; initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultations; and continuity of care with a designated member of the care team. We asked our coder 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 care management services. Our reviewer says that CPT code 99484 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation did not include Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements; initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultations; and continuity of care with a designated member of the care team. Therefore, this code cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the care management services have not been met. Therefore, we decided that the Plan does not have to pay for care management services (99484) provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 19, 
2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemodenervation (64612) provided on March 2, 2020. 
 
You asked the Plan to pay for the chemodenervation. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 64612 is chemodenervation of muscle(s); muscle(s) 
innervated by facial nerve, unilateral (e.g., for blepharospasm, hemifacial spasm).  
 
We asked our coder 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 chemodenervation. Our reviewer says that CPT code 
64612 does not meet criteria for billing or reimbursement consideration. Our reviewer found The medical 
records provided do not include documentation of a Chemodenervation of muscle(s); muscle(s) innervated by 
facial nerve, unilateral (e.g., for blepharospasm, hemifacial spasm) being performed on the billed date of 
service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the chemodenervation have not been met. Therefore, we decided that the Plan 
does not have to pay for chemodenervation (64612) provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel provided on January 14, 
2020. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary and ordered 
by the treating physician. The Plan denied your request. The Plan says there is no claims history showing that 
the ordering provider is treating the enrollee for a medical condition. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing panel provided on January 14, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for endoscopy services (45380) provided on February 15, 2020. 
 
You asked the Plan to pay for the endoscopy services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the full value of the highest valued 
procedure plus the difference was paid. 
 
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 record does not include any documentation showing what has 
been paid. Without this information we are unable to verify that the highest valued procedure plus the 
difference between the next highest and the base was paid. Therefore, we decided that the Plan has to pay for 
endoscopy services (45380) provided on February 15, 2020.  
 
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: 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 necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are generally medically stable and the documentation does not support that you have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical, medicine, and rehabilitation (PMR) physician three times per week. While you are reasonably expected to benefit from physical therapy (PT) and occupational therapy (OT), the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion insulin pump. 
 
You asked the Plan to pre-approve the external ambulatory infusion insulin pump. You say that the records 
provided support the need for the requested device. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that external infusion pumps are covered for certain 
medical indications.  
 
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 external ambulatory infusion insulin 
pump. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee in this case is a 76-year-old male diagnosed with type 2 diabetes mellitus with hyperglycemia. He is 
prescribed metformin twice daily, Pioglitizone daily, Humalog three times a day, and Lantus once a day. A 
recent HgbA1C was 8.9%. A request for an external ambulatory infusion insulin pump was made. The 
provided documentation shows that the enrollee is having issues with compliance and is missing insulin 
injections multiple times daily. There is no provided documentation of the enrollee having completed a 
comprehensive diabetes program, no documentation of the enrollee checking glucose readings at least 4 times 
per day, and there is no documentation of the enrollee having positive beta cell antibody testing or a low C-
peptide. As the above supportive information was not found in the provided notes, the criteria has not been met 
for an insulin pump. 
 
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 external ambulatory infusion insulin pump have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an external ambulatory infusion insulin pump.