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

 We decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on August 9, 2021.  You asked the Plan to pay for the injection of a therapeutic or diagnostic substance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this 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 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 injection of a therapeutic or diagnostic substance have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genomic sequence analysis (CPT code 81455) provided on July 15, 2021.  You asked the Plan to pay for the laboratory testing. You say that this was for Targeted genomic sequence analysis panel and is a covered benefit for a patient with advanced cancer. The Plan states this is used to help determine treatment. The Plan denied your request. The Plan says this 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. Targeted genomic sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the genomic sequence analysis (CPT code 81455) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the anesthesia services rendered on August 13, 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 that procedure code 01992 is inclusive to code 64493.  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 Plan states that procedure code 01992 (anesthesia for diagnostic or therapeutic nerve blocks and injections) is inclusive to code 64493 (paravertebral facet joint injection) and not separately payable; however, the National Correct Coding Initiative (NCCI) does not list an any active code pair edits for these codes. The Plan has not provided any documentation to support that code 01992 is not payable as billed. Therefore, we decided that the Plan has to pay for the anesthesia services rendered on August 13, 2021.   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 specialist office visits (99205, 99214), the insertion of a non-indwelling bladder catheter (51701), a urinalysis (81002), the bladder instillation of anticarcinogenic agent (51720), an intraabdominal pressure test (51797), an electromyography studies (EMG) of anal or urethral sphincter (51784), a complex uroflowmetry (51741), and laboratory services (81002) provided on April 9, 2021, to April 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for specialist office visits, the insertion of a non-indwelling bladder catheter, a urinalysis, the bladder instillation of anticarcinogenic agent, an intraabdominal pressure test, an electromyography studies (EMG) of anal or urethral sphincter, a complex uroflowmetry, and laboratory services. You say that no one mentioned that a referral letter is required, and the provider did not require a primary doctor referral letter when you contract them. You also say that the provider told you that they accept your insurance. The Plan denied your request. The Plan says This provider is not a network provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved in advance.

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 specialist office visits (99205, 99214), the insertion of a non-indwelling bladder catheter (51701), a urinalysis (81002), the bladder instillation of anticarcinogenic agent (51720), an intraabdominal pressure test (51797), an electromyography studies (EMG) of anal or urethral sphincter (51784), a complex uroflowmetry (51741), and laboratory services (81002) provided on April 9, 2021, to April 21, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for SelectMDx testing provided on March 12, 2021.  You asked the Plan to pay for lab test. You say that this testing helps distinguish patients at increased risk for clinically significant prostate cancer from those at very lower risk for aggressive disease. The Plan denied your request. The Plan says that this testing is not covered because there was no documented significant interval increase in prostate-specific antigen (PSA) level.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  This testing was ordered by an in-network physician. The file does not show that the plan provided notice that lab test would not be covered. Under Medicare rules, this means lab test is considered approved by the plan. Therefore, we decided that the Plan has to pay for SelectMDx testing provided on March 12, 2021.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on June 1, 2021.  You asked the Plan to pay for the testing services. You say that medical necessity has been signed off. The Plan denied your request. The Plan says Medicare coverage criteria was not met.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  We looked at the file and the rules. The records do not show that the enrollee's treating physician ordered the testing for a specific medical problem. The physician does not indicate that the results of the testing will impact clinical management. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on August 5, 2021.  You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says this is not a covered screening test. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on October 30, 2020, through November 4, 2020 and billed with a primary diagnosis code of A41.59.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the documentation supports the diagnosis code billed. The Plan denied your request. The Plan says diagnosis code A41.59 is not supported by the medical records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with A41.59. 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 inpatient hospital services. Our reviewer says that there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did not support a diagnosis code A41.59. Our physician reviewer found the enrollee with a history of chronic obstructive pulmonary disease, hypertension, chronic back pain and rheumatoid arthritis was evaluated in the emergency department and found to have a urinary tract infection. On evaluation she was hemodynamically stable but tachycardic. Her white blood cell count was elevated to 15T and her creatinine was 0.78. She was treated with intravenous (IV) fluids, IV antibiotics, steroids and supplemental oxygen. She remained hemodynamically stable throughout the hospitalization.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on October 30, 2020, through November 4, 2020 and billed with a primary diagnosis code of A41.59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on March 9, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99239 is not supported. The service represents a hospital discharge day management of more than 30 minutes. The documentation submitted indicate that 25 minutes of time was spent on discharge services. The documentation does not support the report procedure 99239. The correct CPT code 99238 should have been reported.  This service represents a hospital discharge day management service of 30 minutes of less. 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 the hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the allergen specific IgE; quantitative or semiquantitative testing (86003) provided on January 28, 2021.  You asked the Plan to pay for the testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it appears medically unnecessary to test for 33 IgE immunoassays with no supporting medical documentation.  The Plan must follow Medicare rules. Medicare rules say that the need for such tests is based on the findings during a complete history and physical examination of the patient.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Specifically, the documentation submitted does not include any medical records or clinical information to indicate the need for this testing. There are no records to establish the need for this testing based on the findings during a complete history and physical examination of the member. Therefore, we decided that the Plan does not have to pay for the allergen specific IgE; quantitative or semiquantitative testing (86003) provided on January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (23395) provided April 16, 2021.  You asked the Plan to pay for the surgical services. You say that the service was medically necessary. The Plan denied your request. The Plan says the documentation does not support the procedure 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 23395 is single muscle transfer of any type, to the shoulder or upper arm.  We find that CPT code 23395 is not supported in the medical record. Specifically, the operative report did not include documentation of a single muscle transfer of any type. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (23395) provided April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device for use other than knee (E0936).  You asked the Plan to pre-approve a CPM device. You say that you received a reverse shoulder replacement, not a knee replacement. The Plan denied your request. The Plan says rules for coverage have not been met for the requested item.  The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery.  You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device for use other than knee (E0936).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on September 27, 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 September 27, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies rendered on August 11, 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 a status indicator of I represents a code that is not valid for Medicare purposes.  We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on June 1, 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 procedure code 71045 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, 2 views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on June 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care (CPT code 99309) provided to the enrollee on June 4, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this 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.  Per the Medicare guidelines, the place of service 13 was not the most appropriate place of service. Subsequent nursing facility care (CPT cod 99309), per day shall be used with place of service (POS) 31 (SNF) if the patient is in a Part A SNF stay. They shall be used with POS 32 (NF) if the patient does not have Part A SNF benefits or if the patient is in a NF or in a non-covered SNF stay; we find that Medicare rule for payment for CPT code 99309 has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. 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 subsequent nursing facility care (CPT code 99309) provided to the enrollee on June 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on August 16, 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 August 16, 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: 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 these services could be provided at a SNF, outpatient setting, or home health care. The Plan denied your request. The Plan says the enrollee would benefit from daily inpatient therapy to improve function and independence.  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 there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 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.