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

 We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (CPT code 76942) provided to the enrollee on May 6, 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 covered as billed.  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 service have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76942 and 76937.   This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (CPT code 76942) provided to the enrollee on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a left-knee brace (L1851) and suspension sleeve (L2397) provided on August 11, 2021.  

You asked the Plan to pay for a left-knee brace and suspension sleeve. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.  

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 a left-knee brace and suspension sleeve. Our reviewer says that the items at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee meets criteria for a left-knee brace. Provided records do not document knee instability on examination or a recent injury to or a surgical procedure on the knee(s). There is no documentation that the suspension sleeve meets Medicare criteria for reasonable and necessary in this case.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a left-knee brace and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a left-knee brace (L1851) and suspension sleeve (L2397) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Multi-Gene testing provided on September 23, 2020.  You asked the Plan to pay for the GeneSight Multi-Gene testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 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 CPT code.  We find that CPT code 81479 is not supported in the medical record. Specifically, there is no signed order for this service. In addition, the claim is missing the required DEX Z-code. Based on this information, we decided that Medicare rules for coverage of the GeneSight Multi-Gene testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Multi-Gene testing provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the DecisionDx -Melanoma test provided on February 18, 2021.  You asked the Plan to pay for the DecisionDx -Melanoma test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.    Review of the file shows that the Plan uses Local Coverage Determination (LCD) L37748 to support their denial. However, this LCD is not valid for the provider's billing state of Texas. This means that we are unable to use LCD L37748 to substantiate our decision.  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 DecisionDx -Melanoma test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has aT1a melanoma. There is insufficient literature to support the requested test as a standard of care for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  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 DecisionDx -Melanoma test have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx -Melanoma test provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to waive the copayment charged for lab services provided on February 15,
2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the claim billed by the provider.
The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that been this claim processed correctly. The Plan contract says there will be a $35 copayment for lab services provided by an Outpatient Hospital. In fact, this claim processed with an amount owed which is
less than the normal $35 copayment. The review shows the copayment charged is only $13.56 member
liability. 

The Plan is correct in this case. 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 $35 copayment for outpatient hospital lab services. In this case you have been
asked to pay less than the traditional copayment amount which could be expected. 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 charged for lab services provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on August 27, 2020.  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 G0483 90 (1 Unit) remains 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 obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on August 27, 2020, and received by the lab on August 28, 2020; therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the duplex scan of arterial inflow and venous outflow services coded 93976 provided on April 8, 2021.  

You asked the Plan to pay for the duplex scan of arterial inflow and venous outflow services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93976 for the duplex scan of arterial inflow and venous outflow services is a column II code to column I code 76856. 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 duplex scan of arterial inflow and venous outflow services coded 93976 provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on April 6, 2021.  You asked the Plan to pay for the services provided. You say that the testing meets coverage criteria. The Plan denied your request. The Plan says the billed code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim indicates a place of service as an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided by an out-of-network on June 1, 2021, to July 5, 2021.  You asked the Plan to waive the copayment for physical therapy. You say that this should be processed as in-network. The Plan denied your request. The Plan says the correct copayment has been applied.  

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 $55 copayment for outpatient rehabilitation services/out-of-network.   

You have been asked to pay a $55 copayment for physical therapy. The total amount you are being asked to pay is $110 ($55 x 2 visits = $110). The correct copayments have been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/out-of-network 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 physical therapy provided by an out-of-network provider on June 1, 2021, to July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit (99343), the therapeutic, prophylactic, or diagnostic injection (96372), and the furosemide injection (J1940) rendered by the out-of-network (OON) provider on June 14, 2021.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  

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 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 home visit (99343), the therapeutic, prophylactic, or diagnostic injection (96372), and the furosemide injection (J1940) rendered by the out-of-network (OON) provider on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.  

You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental and investigational.  

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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are not reasonable or 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 the blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the services (CPT code J0604-AX, 90999-G4, Q4081-JB, and A4657) provided to the enrollee from June 2, 2021, through June 30, 2021.  

You asked the Plan to pay for the services. You say that the enrollee's medical condition causes their UUR levels to change on a month-to-month basis as can be seen from the records. You state the modifier will not be the same on the claim unless the enrollee's level stays the same for the months in which the enrollee's getting services. The Plan denied your request. The Plan says that the procedure code is inconsistent with the modifier used.  

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 denial does not provide sufficient specificity to determine which modifier the Plan is saying is incorrect. However, the provider's argument validates the use of modifier G4 for these dates based on the most recent URR test for this date range. Therefore, we decided that the Plan has to pay for the services (CPT code J0604-AX, 90999-G4, Q4081-JB, and A4657) provided to the enrollee from June 2, 2021, through June 30, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  

You asked the Plan to pre-approve the Intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The Intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure to treat back pain.  

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided to the enrollee on September 14, 2020.  You asked the Plan to pay for the laboratory services. 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 laboratory services have not been met. CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, 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 an office setting POS 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Skilled Nursing Facility POS 31. Also, the laboratory results submitted indicate the specimen was collected on September 14, 2020, and received by the lab on September 15, 2020. Of note, the patient resides in Missouri (MO) and the billing laboratory is located in Arizona (AZ); 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 laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided to the enrollee on September 14, 2020.
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 you need IRF services to return to full function. You feel you will not recover fully in a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 

Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intravenous immunoglobulin Gammaked for the enrollee.  

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.  

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  

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 the requested injection is not medically reasonable or necessary. Our physician reviewer found the provider is requesting coverage for new start of Gammaked therapy, a non-preferred intravenous human immunoglobulin to be administered in his office. The enrollee was on Octagam and is requesting change to Gammaked due to availability. The plan requires a trial of Privigen before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.  

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 intravenous immunoglobulin Gammaked for the enrollee.