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

 We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on September 29, 2021.  You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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, we have confirmed that code 70450 is a column II code to column I code 70496. 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 the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on October 25, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on October 25, 2021.   Benefits for these services 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Esophagogastroduodenoscopy (EGD).

You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says the documentation fails to indicate that the member has had a recent negative colonoscopy. Therefore, the Medicare medical necessity criteria are not met as per Local Coverage Determination (LCD): Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350).

The Plan follows Medicare rules. Medicare rules say that Endoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present. 

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 EGD. Our reviewer says that an EGD is not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the requested esophagogastroduodenoscopy meets the Medicare Local Coverage Determination: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic): L35350 coverage criteria. The provided records do not document a colonoscopy negative for a bleeding source with regard to the diagnosis of iron deficiency anemia as required by 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 an EGD have not been met. Therefore, we decided that the Plan does not have to pre-approve an EGD.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to a SNF does not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities in accordance with her weight bearing restriction.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care (ex. home, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spinal cord injection (62320) provided on August 30, 2021.  You asked the Plan to pay for the spinal cord injection (62320). You say that the procedure billed is for subarachnoid injection therefore the policy of interlaminar epidural injections is not applicable. You say that subarachnoid opioids are very effective for decreasing pain and the service should be paid. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of the service.   The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. The rules also say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal cord injection (62320) have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the spinal cord injection (62320) provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve carboplatin, paclitaxel, bevacizumab (Avastin), and pembrolizumab (Keytruda).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has endometrial cancer and the regimen is being requested as second line therapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The regimen is not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve carboplatin, paclitaxel, bevacizumab (Avastin), and pembrolizumab (Keytruda).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services (CPT code(s): 93042 and 99053) provided to the enrollee on May 20, 2021.  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 the services are not covered as 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.  Procedure code 93042 is bundled to 93010, which was billed on the same claim as the denied code. This Procedure to Procedure (PTP) edit has a modifier indicator of 1, modifiers associated with National Correct Coding Initiatives (NCCI) are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Procedure code 93042 shows a modifier indicator of 1, there would need to be an allowed modifier that is recognized by Centers for Medicare and Medicaid Services (CMS). This procedure was billed without a National Correct Coding Initiatives (NCCI) allowed modifier.  Procedure code 99053 denied ass 'z39 Bundled Code - Medicare'. Per the CMS National Physician Fee Schedule Relative Value File (RVU21B), procedure code 99053 has a status indicator of 'B'. CMS states that status code B = Bundled Code. Payment for covered services are always bundled into payment for other services not specified and no separate payment is made. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services (CPT code(s): 93042 and 99053) provided to the enrollee on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99212) provided on October 12, 2021.

You asked the Plan to pay for the office or other outpatient visit. You say that this claim is eligible for separate payment. The Plan denied your request. The Plan says separate payment cannot be made for services included in the anesthesia care package when furnished by the same provider or the same provider specialty within the group practice.

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 99212 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. 

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 office or other outpatient visit. Our reviewer says that the documentation does not support payment for the claim as billed. Our reviewer found the documentation consists of an anesthesia report for a total knee arthroplasty as an outpatient provided on October 11, 2021. No evaluation and management documentation found for October 12, 2021. Provider is stating CPT 99212 is subsequent hospital care. CPT 99212 is office or other outpatient visit. The documentation does not support the patient had a total knee arthroplasty as an outpatient, then returned to office or other outpatient for a visit. This service 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 office or other outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit (99212) provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 25, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 services at issue in this appeal. 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 the services provided by an out-of-network provider on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency anesthesia rendered on August 8, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99140 (emergency anesthesia) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia rendered on August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on June 8, 2021.  You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the coverage criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.   We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the testing be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray of toes (73660) provided on September 29, 2021.  You asked the Plan to pay for the X-ray of toes. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare coding regulations.  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 73660 is a column II code to column I code 73630. 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 the X-ray of toes (73660) provided on September 29, 2021.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.

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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be on an intensive level in an IRF. The enrollee's needs are being safely and effectively met in his current skilled nursing facility. 

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 drug testing (CPT code(s): 80307) and G0482) provided to the enrollee on February 19, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code(s): 80307 and G0482), remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was collected on February 19, 2021, and received by the lab on February 23, 2021. Of note, the enrollee resides in Alabama (AL) and the billing laboratory is located in Tennessee (TN); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code(s): 80307) and G0482) provided to the enrollee on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 23, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 services at issue in this appeal. 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 the services provided by an out-of-network provider on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary genetic testing provided on June 24, 2021.  You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must be submitted for the panel.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and the rules. We find that the testing at issue was billed with multiple codes. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary genetic testing provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the contact lens, hydrophilic, toric, or prism ballast, per lens (V2521) provided August 25, 2021.

You asked the Plan to provide additional payment for the contact lenses. You say that you don't feel the contact lens fitting should have been billed the way it was and applied towards your routine vision allowance. The Plan denied your request. The Plan says your full routine vision allowance has been applied to your eyewear and no additional payment is due.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $120 per calendar year. 

We looked at the file and the Plan's rules. The Plan provided documentation that on August 25, 2021, $55 was correctly paid toward your contact lenses fitting. The remaining $65 of your routine vision allowance was paid towards your contact lenses. Therefore, we decided that the Plan does not have to provide additional payment for the contact lens, hydrophilic, toric, or prism ballast, per lens (V2521) provided August 25, 2021.