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

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 28, 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. Medicare rules say that 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 these 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 the laboratory services rendered on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint nerves. 
 
You asked the Plan to pre-approve the SI joint RFA procedure. You say that the enrollee would benefit from 
this treatment to reduce pain. The Plan denied your request. The Plan says clinical studies have not proven this 
treatment effective. 
 
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 SI joint RFA procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not 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 SI joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 (87150) provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99214) provided on 
February 21, 2022. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD-10-CM code. 
 
We find that CPT code 99214 is not supported in this case. Specifically, the code was inappropriately billed 
with two unilateral diagnosis codes when there is available a more appropriate and specific bilateral diagnosis 
code. Based on this information, we decided that Medicare rules for coverage of an office or other outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for an office or other 
outpatient visit (99214) provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan 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, a cardiovascular risk assessment panel, 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 laboratory services rendered on August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydrogen breath test. 
 
You asked the Plan to pre-approve the breath test. You say that the enrollee has had pain after eating and 
diarrhea since a trip to Mexico where she may have ingested a toxin. It is felt this testing is needed to check for 
small bowel bacterial overgrowth. The Plan denied your request. The Plan says this test is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that hydrogen breath testing for SBO are nationally 
noncovered. Therefore, we decided that the Plan does not have to pre-approve a hydrogen breath test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pharmacogenomic panel (81225, 81226, 81227, 81231, 
81238, 81240, 81241, 81291, 81306, 81335, 81401) provided on November 19, 2021. 
 
You asked the Plan to pay for a pharmacogenomic panel. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that if one laboratory 
procedure evaluates multiple genes using a next generation sequencing 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 CPT code. 
 
We find that CPT codes 81225, 81226, 81227, 81231, 81238, 81240, 81241, 81291, 81306, 81355, and 81401 
are not supported in the medical record. Specifically, these codes were used to report a panel, which should be 
billed with one code. Based on this information, we decided that Medicare rules for coverage of a 
pharmacogenomic panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
pharmacogenomic panel (81225, 81226, 81227, 81231, 81238, 81240, 81241, 81291, 81306, 81335, 81401) 
provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient psychiatric hospital services provided to the enrollee from 
November 1, 2021, to November 30, 2021. 
 
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 that payment is not allowed for this claim because the number of absence days submitted is 
greater than the number of days for the billed stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan is using rules for home 
health services, when the services at issue in this case were inpatient psychiatric services. Therefore, we 
decided that the Plan has to pay for inpatient psychiatric hospital services provided to the enrollee from 
November 1, 2021, to November 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: Lab
Decision: Favorable

We decided that the Plan has to pay for the infectious agent antigen detection (87631) provided January 6, 2022.
You asked the Plan to pay for the laboratory service. You say that CMS LCD L37348 has a complete list of covered diagnosis codes under Article A56974 and the reported ICD10 code R05.1 is listed as a covered diagnosis code for CPT 87631. The Plan denied your request. The Plan says that procedure code 87631 has not met the associated diagnosis code relationship criteria.
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. In this case, medical records was missing from the original file. The file says CPT code 87631 was submitted. The definition for CPT code 87631 is Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets. The Plan denied that the submitted documentation indicates there were more than five targets. A request for information was sent to the Plan with a due date of 06/22/2022. As of the date of this letter, the plan has not responded to our request and/or submitted the required records. Therefore, we decided that the Plan has to pay for the infectious agent antigen detection (87631) provided January 6, 2022.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening (71271) for the enrollee.
You asked the Plan to pre-approve the requested LDCT scan. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is not asymptomatic.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. 
We reviewed the file and the Medicare rules. We do not find a 20 pack-year smoking history or an absence of signs/symptoms of lung cancer. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening (71271) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine disposable supplies (A0382) and ambulance
oxygen and oxygen supplies (A0422) provided on December 15, 2021.
You asked the Plan to pay for the routine disposable supplies and ambulance oxygen and oxygen supplies. You
say that you would like to appeal these services. The Plan denied your request. The Plan says these codes are
not covered by Original Medicare, and therefore, will not be covered by the health plan.
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen,
is included in the fee schedule payment. Medicare rules also say that an ambulance must have customary
patient care equipment and first aid supplies which are considered part of the general ambulance service and
payment for them is included in the payment rate for the transport.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the routine disposable supplies and ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the routine disposable supplies (A0382) and ambulance oxygen and oxygen supplies (A0422) provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power scooter (K0823) provided October 23, 2021.
You asked the Plan to pay for the power scooter. You say that the power scooter was medically necessary. The Plan denied your request. The Plan says the claim was billed with an inappropriate modifier.
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 K0823 is not supported in the medical record. Specifically, the KJ modifiers were incorrectly billed for the capped rental item. Based on this information, we decided that Medicare rules for coverage of the power scooter have not been met. Therefore, we decided that the Plan does not have to pay for a power scooter (K0823) provided October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided November 10, 2021.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says this service was for screening purposes and is non-covered.
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, CxBladder, 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 lab services (81479) provided November 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daliresp for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Daliresp for the enrollee.
Benefits for this drug 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: Lab
Decision: Favorable

We decided that the Plan has to pay for the Hepatitis C testing rendered on November 4, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the Hepatitis C testing is not covered; however, the Plan has not provided any medical records to show that you do not meet the criteria for coverage of this test. Therefore, we decided that the Plan has to pay for the Hepatitis C testing rendered on November 4, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says Criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found The patient appears to be more stable and improving and should only require short-term additional acute care services that can safely be completed at the current facility until more appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast tomosynthesis rendered on January 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 the services are not covered.
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 code G0279 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 breast tomosynthesis rendered on January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levemir Flextouch for the enrollee.
You asked the Plan to pre-approve this drug. You say that this has been successful in the enrollee's treatment. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Levemir Flextouch for the enrollee.
Benefits for this drug 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 anesthesia services provided to the enrollee on January 25, 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 services were not pre-certified.
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 anesthesia services provided to the enrollee on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on January 27, 2022.
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 subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on January 27, 2022.