Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve private duty nursing (PDN) services (S9124, S9123).

You asked the Plan to pre-approve PDN services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested nursing services.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 PDN services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the need for a private duty nurse is considered skilled. Although the enrollee is at home and has a chronic tracheostomy, she has been medically stable. The tracheostomy is not new. The management of a tracheostomy is considered skilled when an enrollee is newly discharged from the hospital or is having complications that can only be managed by a skilled professional under the direction of a physician. There is no indication that the enrollee has a new or malfunctioning feeding tube, parental medications or complex wound care issues. There is no indication that the enrollee had any recent medication changes or hospitalizations. There has not been a recent decline in function and the enrollee has been medically stable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PDN services have not been met. Therefore, we decided that the Plan does not have to pre-approve private duty nursing (PDN) services (S9124, S9123).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spravoto.

You asked the Plan to pre-approve Spravoto. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spravoto.

Benefits for Spravoto 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99220 billed for June 14, 2022.

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 99220 is not supported.

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 99220 is initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.

We find that CPT code 99220 is not supported in the medical record. Specifically, there is no documentation of a comprehensive history, comprehensive examination, and medical decision making of high complexity. 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 pay for procedure code 99220 billed for June 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 10, 2022 to October 7, 2022.

You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code.

We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 10, 2022 to October 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol.

You asked the Plan to pre-approve Dronabinol. You say that the medication is 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. Medicare rules say that oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dronabinol have not been met. Therefore, we decided that the Plan does not have to pre-approve Dronabinol.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 3, 2022.

You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 77065 and G0279 billed for date of service September 13, 2022.

You asked the Plan to pay for procedure codes 77065 and G0279. You say that you disagree with the denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.

In this case, the MUE for CPT codes 77065 and G0279 is 1. The MAI value for this code is 2. You billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure codes 77065 and G0279 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 77065 and G0279 billed for date of service September 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport provided on August 17, 2022.

You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that the medical records provided support the need for the ambulance transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.

Our physician reviewer found the transportation via ambulance from the emergency department to the enrollee's home was not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition.

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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on September 2, 2022.

You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99239 billed for May 21, 2022.

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 99239 is not supported.

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 99239 is hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of a hospital discharge day management note with a duration time of 31 minutes or more. 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 pay for procedure code 99239 billed for May 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99291 billed for June 22, 2022, to June 23, 2022.

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 99291 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care evaluation and management. 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 pay for procedure code 99291 billed for June 22, 2022, to June 23, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 1, 2022.

You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 2, 2021.

You asked the Plan to pay for procedure code 87640. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641.

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 87640 is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) services (97110, 97112, 97140, 97162) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve PT services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee must use network providers to get medical care and services. Medically necessary care is available in network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) services (97110, 97112, 97140, 97162) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on April 25, 2022.

You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided on April 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes R0070 and Q0092 provided to the enrollee on July 15, 2022.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) codes R0070 and Q0092 remain not supported.

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 the denied codes is:

HCPCS R0070:

Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen

HCPCS Q0092:

Set-up portable x-ray equipment

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the description of the ultrasound exams done on 10/29/22 do not include the description of portable ultrasound equipment for the duplex arterial and ankle brachial index (ABI) exams done that day. While it can be assumed that portable exams were necessary, the portable nature of the exams at the bedside need to be detailed for reimbursement for the charges R0070 and Q0092 to be paid and such documentation is not in the submitted records.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes R0070 and Q0092 provided to the enrollee on July 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-abdominal omental flap provided to the enrollee on 
June 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 49905 is "Omental flap, intra-abdominal (List separately 
in addition to code for primary procedure)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the elements of CPT 49905 are 
not present in the documentation. The report states that the omentum was retracted as part of the main 
procedure, the laparoscopic colectomy with ileocolostomy. The record does not support that a separate omental 
flap was created to repair a defect.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an intra-abdominal omental flap provided to the enrollee on June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 14, 2022, billed 
with codes 81210, 81275, 81276, 81292, 81295, 81289, 81301, 81311, 81321, 81194, 81206, 81235, and 
81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 14, 2022, billed with codes 81210, 81275, 81276, 81292, 81295, 81289, 81301, 81311, 81321, 81194, 
81206, 81235, and 81309.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 18, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service October 18, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee arthroplasty (27447) provided on July 6, 2022. 
 
You asked the Plan to pay for the knee arthroplasty. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the knee arthroplasty have been met. No medical records were provided. The records show that the plan made multiple requests for this information 
and none were provided. Therefore, we decided that the Plan does not have to pay for a knee arthroplasty 
(27447) provided on July 6, 2022.