Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 8, 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 payment for this service is always bundled into payment for other services. 
 
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 99100 is not supported in the case file. Specifically, this code has a status indicator of B 
according to the Medicare Physician's Fee Schedule. This means that payment for this service is bundled into 
payment for other codes, and this code cannot be billed separately. 
 
 
 
 
  
 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 anesthesia services provided to the enrollee on 
July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine wellness panel provided on March 3, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the clinical 
effectiveness has not been demonstrated. 
 
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. 
 
We looked at the file and the rules. In this case, the medical records provided do not show that the testing was 
ordered due to signs or symptoms the enrollee was experiencing. The testing is not considered necessary on the 
basis of a diagnosis code. The testing appears to have been ordered for screening purposes. Medicare does not 
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the urine 
wellness panel provided on March 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not need skilled nursing or 
skilled therapy services, or a combination of these services, on a daily basis. The enrollee does not require the 
necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Docetaxel and Nivolumab. 
 You asked the Plan to pre-approve Docetaxel and Nivolumab. You say that these drugs are medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says these services associated with a 
clinical trial are not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Docetaxel and Nivolumab as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve Docetaxel and Nivolumab.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on September 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 76705 may be eligible for payment when billed with 
CPT code 93976. However, the claim does not show that the code at issue was billed with a modifier suitable 
for payment. 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 abdominal ultrasound 
provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 20, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim billed a place of service as an office setting (11). However, the 
records show that the specimen was obtained at a psychiatric center. The file also shows that validity testing 
(code 83789) was billed. Providers performing validity testing on urine specimens used for drug testing shall 
not separately bill the validity testing. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing services provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as 81, an independent laboratory. The 
records provided do not indicate the sample was taken at an independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing services provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) and wound debridement (11044) 
provided on August 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and wound debridement. You say that this was for a follow-up 
visit from a surgery that was performed on the patient on August 16, 2021. The Plan denied your request. The 
Plan says the non-urgent services are not authorized because the provider is a non-network provider with the 
Plan, and the servicing provider is also listed as the referring provider. The Plan also says that no necessity for 
an out-of-network provider, such as an urgent or emergency situation has been documented. 
 
 
 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 at issue in this case is not a network provider with the Plan. 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 an office visit and wound debridement. Our reviewer says that this does not meet 
criteria. Our physician reviewer found that after review of the medical progress note dated August 26, 2021, it 
appears that this patient underwent routine debridement of a foot ulceration and there does not appear to be a 
medical reason as to why this level of care could not be performed by an in-Plan podiatrist. Our doctor also 
found that the medical documentation does not support that this treatment was urgently or emergently 
performed, and therefore, it is his opinion that it was not medically reasonable or necessary for the member to 
continue seeing the out-of-network provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit and wound debridement have not been met.  
 
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 pay for an office visit and wound debridement. Therefore, we 
decided that the Plan does not have to pay for an office visit (99213) and wound debridement (11044) provided 
on August 26, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that these shots help you walk better and without them 
you are in extreme pain. The Plan denied your request. The Plan says the denial of authorization for this drug is 
correct, because Orthovisc is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Orthovisc. Our reviewer says that you 
do not meet the Medicare criteria for the requested use of Orthovisc. Our physician reviewer found Orthovisc is 
indicated for osteoarthritis pain in patients who have not responded to conservative non-pharmacologic therapy 
or to simple analgesics. However, in light of your recent blood clots, this injection is not medically reasonable 
or necessary. Although some studies showed improvement n pain, stiffness, and function with this therapy, 
patients did not achieve minimum clinically important improvement. Therefore, the clinical efficacy of 
Orthovisc was not demonstrated and use of it for your indication cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Orthovisc.
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 this is medically necessary. The Plan denied your 
request. The Plan says that your needs can be met at a lower level of care. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF care. 
 
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: Favorable

We decided that the Plan has to pay for the laboratory services provided on August 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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, the Plan denied payment for the laboratory services stating that the
date of service on the claim does not align with the records. However, the file shows that the laboratory
specimen was received by the lab on August 12, 2021. The Plan has not provided any documentation that the
specimen received date would not be the correct date of service to report for laboratory services based on
Medicare criteria. Therefore, we decided that the Plan has to pay for the laboratory services provided on
August 12, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy (52000) provided on April 13, 2021. 
  You asked the Plan to pay for the cystourethroscopy (52000). You say that records are attached for 
reprocessing. The Plan denied your request. The Plan says there is no modifier allowed with this code pair. 
 
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 52000 
is a column II code to column I code 51040. This claim has not been billed with a 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 cystourethroscopy (52000) provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim billed a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy with biopsy (31625-59) provided on 
September 20, 2021. You asked the Plan to pay for the bronchoscopy with biopsy. You say that these services were billed correctly 
and should be paid. The Plan denied your request. The Plan says the service is not supported as billed. A 
National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edit exists between codes 31625 and 
31628. While this code pair does allow for a modifier to bypass the edit, and a modifier with this capability was 
used, the documentation does not support that modifier 59 was used appropriately in this case. Modifier 59 and 
other NCCI-associated modifiers should not be used to bypass an NCCI PTP edit unless the proper criteria for 
use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any 
NCCI-associated modifier used. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 bronchoscopy with biopsy Our reviewer 
says that this service is not supported as billed. Our physician reviewer found that Current Procedural 
Terminology (CPT) code 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 
performed; with bronchial or endobronchial biopsy(s), single or multiple sites) and CPT code 31628 
(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung 
biopsy(s), single lobe) were provided and billed for this date of service. The submitted procedure report 
describes endobronchial biopsy and transbronchial biopsy both performed in the upper right lobe anterior 
segment. Therefore, code 31625 would be included with code 31628 as they were both performed in the same 
area. It is not appropriate to bill these services using the 59 modifier in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bronchoscopy with biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the bronchoscopy with biopsy (31625-59) provided on September 20, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you have documented skilled nursing needs. You 
have a new ostomy with surrounding wounds. You do not have documented skilled therapy needs.  You appear 
to be at/near a plateau in function. Daily skilled services are not required to establish a maintenance program or 
to prevent deterioration of your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on February 24, 2021. 
 
You asked the Plan to pay for the telehealth visit. You say that medical records are attached to reprocess the 
claim. The Plan denied your request. The Plan says we are unable to confirm if this visit took place. 
 
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 Medicare rules for 
coverage of the telehealth visit have not been met. Specifically, the records do not support a medically 
appropriate history and/or examination and high level of medical decision making was performed. Therefore, 
we decided that the Plan does not have to pay for the telehealth visit provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. If an independent lab bills for services, the place where the sample was 
taken is reported as the place of service. In this case, the claim identifies the place of service as an independent 
laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on July 21, 2021.