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

 We decided that the Plan does not have to pay for aCompGx comprehensive pharmacogentic panel and the cardiovascular NGS panel (CPT code(s): 81479, 81400, 81355, 81328, 81291, 81231, 81330, 81227, 81226, 81225, 0033U, 0032U, and 0031U) provided to the enrollee on May 12, 2021.  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 there is not documentation of a face-to-face provider encounter nor documentation to support how the testing will impact the enrollee's care. The Plan states the performance of multiple molecular tests regardless of whether the requisition lists the tests as a panel or individually and completed on a single sample is considered to be a panel of tests and should be billed under a single CPT code to prevent stacking of codes. The Plan states the proprietary lab is requesting coverage of the comprehensive panel by stacking codes.  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 test at issue in this appeal, the laboratory services, is being 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 aCompGx comprehensive pharmacogentic panel and the cardiovascular NGS panel (CPT code(s): 81479, 81400, 81355, 81328, 81291, 81231, 81330, 81227, 81226, 81225, 0033U, 0032U, and 0031U) provided to the enrollee on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided to the enrollee on August 30, 2021.  

You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the service(s).  

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 injection have not been met. There were no medical records provided to verify medical necessity. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided to the enrollee on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of home oxygen.  You asked the Plan to pre-approve continued home oxygen. You say that home oxygen continues to be necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for continued home oxygen use is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that home oxygen therapy is subject to the criteria listed 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 continued home oxygen. Our reviewer says that the continued use of home health oxygen is not medically reasonable and necessary. Our physician reviewer found continued home supplemental oxygen is not medically necessary because coverage criteria are not met.  The patient was hospitalized with septic shock and pneumonia on November 22, 2021 and was discharged on December 11, 2021.   Home oxygen was approved at discharge for 3 months based on findings of hypoxemia breathing room air at rest in the hospital on the day of discharge. The medical records do not include any further information on the patient's oxygenation or need for supplemental oxygen since discharge. The patient may have recovered sufficiently from that acute illness, that he no longer requires home oxygen.  Evidence of continued need for oxygen, based on measurements of oxygenation in the patient's current state, are required.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home oxygen have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of home oxygen.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic exercises provided on October 26, 2020.  You asked the Plan to pay for the therapeutic exercises. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises provided on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81295 and 81298) provided on March 8, 2021.  You asked the Plan to pay for codes 81295 and 81298. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 81295 and 81298 are column II codes to column I code 81432. 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 laboratory services (81295 and 81298) provided on March 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vascular study services (93976) provided on September 20, 2021.  You asked the Plan to pay for the vascular study services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93976 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 vascular study services (93976) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia (01992) provided on June 30, 2021.  

You asked the Plan to pay for anesthesia (01992). You say that the local coverage determination supports the medical necessity of billing CPT code 01992. You say that the procedure was done using general anesthesia and is separately payable service due to the physical status of the patient at the time of service. The Plan denied your request. The Plan says the anesthesia service reported is inconsistent with the surgical procedure reported.  

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 01992 is anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position.  

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 anesthesia (01992). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that there is a more appropriate anesthesia code to bill when procedure 64483 is performed. Therefore, CPT code 01992 is not eligible for reimbursement.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia (01992) have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01992) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (CPT code 64454) provided to the enrollee on August 23, 2021.  

You asked the Plan to pay for the injection. You say that the service was necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of this right genicular nerve block in the setting of knee osteoarthritis have not been demonstrated in the peer-reviewed literature.  

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 the injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures prior to injection. Regardless, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested injection, anesthetic agent and/or steroid; genicular nerve branches, including imaging guidance when performed (64454) on August 23, 2021, was not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (CPT code 64454) provided to the enrollee on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided on August 9, 2021.  

You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.  

The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided on August 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 4 skilled nursing visits (G0299).  

You asked the Plan to pre-approve home health services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.  

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 home health services. Our reviewer says that the requested 4 skilled nursing visits are not medically necessary. Our physician reviewer found there is no documentation that further skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the latest medical records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. The reviewer found that enrollee and caregiver teaching has been documented. The reviewer also found that no medical notes from the enrollee's treating physician are provided documenting an order or need for additional skilled nursing services. Therefore, the reviewer found that the requested skilled nursing visits are not medically reasonable or 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 home health services have not been met. Specifically, the file does not indicate that the enrollee requires skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Therefore, we decided that the Plan does not have to pre-approve 4 skilled nursing visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided on October 18, 2021.  

You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the service(s).  

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 injection have not been met. There were no medical records provided to verify medical necessity. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided on October 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Ultrasound (76700) provided on October 4, 2021.  You asked the Plan to pay for code 76700. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 is a column II code to column I code 93976. 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 Ultrasound (76700) provided on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the enrollee was recommended for rehabilitation following knee amputation. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.     

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the 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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the urine PCR panel testing (CPT code(s): 87511, 87481, 87798) provided on July 21, 2021.  

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services were not medically necessary and are experimental.  

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 the testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records did not support why a reflex culture and sensitivity was not performed in lieu of these tests. The clinical value of PCR testing in the setting of urinary tract infections remains unproven in the peer-reviewed medical literature. The review has determined that the medical records provided did not meet the requirements listed in the NCD for Medicare coverage. The items/services at issue in this case were not medically reasonable or 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR panel testing (CPT code(s): 87511, 87481, 87798) provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided on August 30, 2021.  

You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.  

The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  

The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance(s) (CPT code 62320) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Injection procedure for extremity venography (36005) provided on September 1, 2021.  You asked the Plan to pay for code 36005. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 36005 is a column II code to column I code 70553. 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 Injection procedure for extremity venography (36005) provided on September 1, 2021.