Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pay for the infusion catheter maintenance supplies (A4221), infusion supplies (A4222) and milrinone lactate injection (J2260) provided from July 9, 2021, through July 15, 2021.  You asked the Plan to pay for the infusion catheter maintenance supplies (A4221), infusion supplies (A4222) and milrinone lactate injection (J2260). You say that the supporting documents show the services are medically necessary and the claim should be reprocessed for payment. The Plan denied your request. The Plan says that the documentation did not include proof of delivery therefore, the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of delivery documentation on file.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infusion catheter maintenance supplies (A4221), infusion supplies (A4222) and milrinone lactate injection (J2260) have been met. Specifically, the documentation clearly includes a legible delivery slip. Therefore, we decided that the Plan has to pay for the infusion catheter maintenance supplies (A4221), infusion supplies (A4222) and milrinone lactate injection (J2260) provided from July 9, 2021, through July 15, 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: Favorable

 We decided that the Plan has to pay for the medical services provided on July 26, 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 that the services provided have been denied due to a provider billing issue.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to address what the provider billing issue is in this case. Additionally, the Plan did not address whether this provider is now your assigned primary care physician. Therefore, we decided that the Plan has to pay for the medical services provided on July 26, 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 laboratory services rendered on February 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 were not billed correctly.  The Plan must follow Medicare rules. The rules say that modifier -91 may be used to indicate that a test was performed more than once on the same day for the same patient, only when it is necessary to obtain multiple results in the course of treatment.  We looked at the file and Medicare rules. The file shows that procedure code 87798 (infectious agent detection by nucleic acid) was billed with modifier -91 but a subsequent test was not performed in the same day.  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 the laboratory services rendered on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on July 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and the provider did not know that the facility failed to get prior authorization for the enrollee. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for testing for Carbamazepin (80157), Levetiracetam (80177), Topiramate (80201), Digoxin (80162), Clozapine (80159), and Haloperidol (80173) provided on February 3, 2021.  You asked the Plan to pay for testing for Carbamazepin, Levetiracetam, Topiramate, Digoxin, Clozapine, and Haloperidol. You say that this is supported in the records. The Plan denied your request. The Plan says these tests are not documented.  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 codes 80157, 80159, 80162, 80173, 80177, 80201 are not supported in the medical record. Specifically, testing for these specific drugs is not documented in the records. Based on this information, we decided that Medicare rules for coverage of testing for Carbamazepin, Levetiracetam, Topiramate, Digoxin, Clozapine, and Haloperidol have not been met. Therefore, we decided that the Plan does not have to pay for testing for Carbamazepin (80157), Levetiracetam (80177), Topiramate (80201), Digoxin (80162), Clozapine (80159), and Haloperidol (80173) provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on August 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 20, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the complex cystometrogram (51729) provided on March 10, 2021.  You asked the Plan to waive the copayment for the cystometrogram. You say that this service did not happen. The Plan denied your request. The Plan says medical records, including results of this test, were submitted for review. This claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $295 copayment for outpatient surgery services provided in an outpatient hospital setting.   Medical documentation was provided to support that this test was provided on March 10, 2021. You have been asked to pay a $295 copayment for the cystometrogram. The cystometrogram, billed with code 51729, is classified as a surgical procedure and was performed in an outpatient hospital setting. 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 the complex cystometrogram (51729) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound debridement (11042) provided on July 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for wound debridement. You say that the service was rendered due to medical necessity and patient care was provided as an urgent request from the medical director to avoid wound complications. You also say that due to the patient medical condition, your physician provided care in good will without requesting an authorization to avoid delay in care, which could result in medical complications. The Plan denied your request. The Plan says neither the provider nor the nursing facility obtained prior authorization for this visit and the services received were neither urgent nor emergent.  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 wound debridement (11042) provided on July 29, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and related accessories.  You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 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 pre-approve a Group 3 power wheelchair. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee meets criteria for use of a power mobility device but not for use of the specific device requested because the enrollee does not require multiple power options and the requested accessories. The documentation does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder.  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 Group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and related accessories.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 provided on June 18, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  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 targeted genomic sequence analysis panel at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on January 14, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special stain including interpretation and report coded 88312 and the surgical pathology services coded 88305 provided on June 17, 2021.  You asked the Plan to pay for the special stain including interpretation and report and the surgical pathology services. 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 codes 88312 and 88305 are not supported in the medical record. Specifically, hospital bundling rules exclude payment to suppliers of the technical component (TC) of a radiology service for beneficiaries in a hospital stay; therefore, this service is considered consolidated billing. Payment for the billed global service for codes 88312 and 88305 have not been met. Based on this information, we decided that Medicare rules for coverage of the special stain including interpretation and report and the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the special stain including interpretation and report coded 88312 and the surgical pathology services coded 88305 provided on June 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the upper endoscopy rendered on June 22, 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 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 43255 (upper endoscopy) and 43239 (upper endoscopy with biopsy). Code 43255 is a column II code with a modifier indicator of 1 when billed with column I code 43239. Code 43255 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 upper endoscopy rendered on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound care services provided to the enrollee on July 22, 2021.  You asked the Plan to pay for the services. You say that due to the enrollee's medical condition, the physician provided care in good will without requesting an authorization to avoid a delay in care which could have resulted in medical complications. The Plan denied your request. The Plan says prior authorization was not obtained.  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 wound care services provided to the enrollee on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the new patient visit provided on August 15, 2020.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the exam was not billed per guidelines.    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 99204 is outpatient visit for the evaluation and management of a new patient. We find that this enrollee previously received a new patient visit from a provider in the same physician group with the same physician specialty within the last 3 years.   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 new patient visit provided on August 15, 2020.
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 March 3, 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 service is 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. Healthcare Common Procedure Coding System (HCPCS) code G0483 (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 March 3, 2020, and received by the lab on March 4, 2020; 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 G0483) provided to the enrollee on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use (CPT code 90715) and Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use (CPT code 90750) provided on January 8, 2021, and March 30, 2021.  You asked the Plan to pay for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the services are not covered.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use (CPT code 90715) and Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use (CPT code 90750) provided on January 8, 2021, and March 30, 2021.   Benefits for the 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on February 3, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on February 3, 2021.