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

We decided that the Plan does not have to pay for established patient domiciliary or rest home visit (99336) provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that it was medically necessary for the enrollee to receive the treatment by the doctor, and you did not know that the facility failed to get preauthorization for this enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 established patient domiciliary or rest home visit (99336) provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) infrared light therapy (97026) provided April 14, 2021.
You asked the Plan to pay for the acupuncture services. You say that please review. Attached are medical records for this date of service. The Plan denied your request. The Plan says the acupuncture services were rendered by a non-covered provider type. Infared light therapy is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture services were rendered by a licensed acupuncturist, not a physician. The service must be provided by a legally qualified physician practicing within the scope of their license. The provider is not supervised by a physician, PA, or NP/CNS. There was no documentation provided to support infrared light therapy was performed on this date. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) infrared light therapy (97026) provided April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminotomy (63044) provided on July 14, 2021.
You asked the Plan to pay for the laminotomy (63044). You say that the service was performed at a different level than what was fused. You say that the operative report should be reviewed, and the code processed for payment. The Plan denied your request. The Plan says procedure code 63044-50 is not supported by the medical records submitted.
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 63044 is laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure).
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laminotomy (63044). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report states "decompressive laminectomy, partial facetectomy, as well as bilateral foraminectomies were performed", but this procedure cannot be verified. Since the procedure is not documented in the operative report, this bilateral procedure code cannot be confirmed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laminotomy (63044) have not been met. Therefore, we decided that the Plan does not have to pay for the laminotomy (63044) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64420) provided on August 20, 2021.
You asked the Plan to pay for injections. You say that this is supported in the records. The Plan denied your request. The Plan says this exceeds MUE.
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 64420 is 2. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64420) provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors for the enrollee.

You asked the Plan to pre-approve the sensors. You say that these are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors for the enrollee.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs appear to be custodial and, as a practical matter, can be provided at a lower level of 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for application of a modality to 1 or more areas; hot or cold
packs (CPT code 97010) provided to the enrollee on October 18, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is 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. CPT code 97010 has a status code of B which
indicates that payment for covered services is always bundled into payment for other services not specified.
There will be no RVUs, or payment amounts for these codes, and no separate payment is ever made. When
these services are covered, payment for them is subsumed by the payment for the services to which they are
incident. 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 application of a modality to 1 or more areas; hot or cold packs (CPT code 97010) provided to the
enrollee on October 18, 2021.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to waive the $30 copayment for the endoscopy. We decided that the Plan does not have to waive the $100 copayment for the endoscopy .

You asked the Plan to waive the copayment for the endoscopy. You say that you should not have a cost share. The Plan says that the cost share was applied correctly.

We decided that the Plan has to waive the $30 copayment for the endoscopy.

The Plan's EOC does not clearly state that you would have to pay separate copayments for one service. Therefore, we decided that the Plan has to waive the $30 copayment for the endoscopy.

We also decided that the Plan does not have to waive the $100 copayment for the endoscopy.

The EOC clearly states you are responsible for a $100 copayment for care provided in a certified ambulatory surgical center. Therefore, we decided that the Plan does not have to waive the $100 copayment for the endoscopy .

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 pay for imaging services provided to the enrollee on August 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 an appropriate modifier was not billed in this case.
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 70544 is a column II code to column I code 70551. 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 imaging services provided to the enrollee on August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation that you will be enrolled in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression is covered if you are enrolled in an approved clinical study. We looked at the file and Medicare rules. The file does not indicate you are enrolled in a clinical study. 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 pre-approve percutaneous image-guided lumbar decompression (0275T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has 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 pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspiration remains experimental for use in spinal surgery as bone graft material. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve bone marrow aspiration for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0480, 83789, 80307) provided on August 9, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (G0480, 83789, 80307) provided on August 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you were mobile and could perform activities of daily living. You say that you suddenly could not get out of bed. You say that you have been evaluated by an in-home primary care physician for blood work. You say that you could not get up and walk, stand to perform activities of daily living, care for yourself, or feed yourself. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that there is no documented need for daily skilled therapy.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The enrollee does require skilled therapy services, but not on a daily basis. There is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. There is no documentation that services in the home with home health care or in a long-term care facility on a part-time basis would be inappropriate 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for 4Kscore testing provided on March 13, 2021.
You asked the Plan to pay for 4Kscore testing. You say that the referring physician determined that this testing
was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because the enrollee refused a digital rectal examination (DRE) so this testing did not meet coverage
criteria.
The Plan must follow Medicare rules. Medicare rules say that 4Kscore testing that does not contain certain
components, such as a digital rectal examination (DRE), is not considered to be medically reasonable and
necessary.
We looked at the file and Medicare rules. The record shows that the enrollee refused DRE, so this testing is
missing a component required for coverage. Based on this information, we decided that Medicare rules for
coverage of 4Kscore testing have not been met. Therefore, we decided that the Plan does not have to pay for
4Kscore testing provided on March 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device (22854) and the anterior instrumentation (22845) provided on June 11, 2021.
You asked the Plan to pay for the insertion of intervertebral biomechanical device (22854) and the anterior instrumentation (22845). You say that there are no disqualifications specified in billing the two procedures together. You say that the claim was billed correctly and should be processed for payment. The Plan denied your request. The Plan says an edit exists between 22845 and 22854 and an appropriate modifier was not billed with this edit. The Plan also says that CPT code 22854 is not supported by the medical records.
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 say that the Correct Coding Initiative was developed to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. In this case, the CPT Code Manual definition of code 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 22845 is anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the insertion of intervertebral biomechanical device (22854) and the anterior instrumentation (22845). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not describe a vertebral body resected, and hole cored out of the vertebral bodies above and below the removed vertebrae in order to secure a biomechanical device into the intervertebral disc space.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 22845 is a column II code to column I 22854. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria for CPT code 22845 have not been met. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of intervertebral biomechanical device (22854) and the anterior instrumentation (22845) have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device (22854) and the anterior instrumentation (22845) provided on June 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery (19125, 19281, 76098, 88307, A6403, J0690, J2250, J2370, J2405, J2704, J3010, J3490, J8501) provided on May 5, 2021.

You asked the Plan to pay for outpatient surgery. 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 e Outpatient Code Editor (OCE) will return to the provider any claim that reports a code for a device-intensive procedure that does not also report at least one device code required for that procedure. If the claim is returned to the provider for failure to pass the edit, the hospital will need to modify the claim by either correcting the procedure code or ensuring that one of the required device codes is on the claim before resubmission. 

We looked at the file and Medicare rules. The claim at issue included a device intensive procedure (19281) but did not include a device code. Based on this information, we decided that Medicare rules for coverage of outpatient surgery have not been met. Therefore, we decided that the Plan does not have to pay for outpatient surgery (19125, 19281, 76098, 88307, A6403, J0690, J2250, J2370, J2405, J2704, J3010, J3490, J8501) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology genetic testing services provided on May 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the oncology genetic testing services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

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 the oncology genetic testing services provided on May 3, 2021 by an out-of-network (OON) provider.