Persius/hicric huggingface dataset:
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 4, 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 October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on September 16, 2021.  You asked the Plan to pay for the CGM supplies. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says the Plan has previously paid for CGM supplies that overlap the current supply period being reported.  The Plan must follow Medicare rules. Medicare rules say that billing more than 1 UOS per 30 days of K0553 will be denied as not reasonable and necessary.   We looked at the file and Medicare rules. In this case, the Plan has provided documentation that K0553 was paid on September 9, 2021. Therefore, payment will not be made for the claim for K0553 provided on September 16, 2021, as it is within the 30-day current supply period. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for other procedures on the esophagus coded as 43499 provided on June 15, 2021.  You asked the Plan to pay for the medical services coded 43499. You say that this claim has been billed correctly. The Plan denied your request. The Plan says the documentation does not support the code 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, the CPT Code Manual definition of code 43499 is Other Procedures on the Esophagus.  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 medical services coded 43499. Our reviewer says that the documentation does not support payment for the services billed. Our reviewer found the documentation shoes that the provider reports after claim denial the "unlisted" procedure code is reported for a "White Light and Narrow Band Imaging (NBI) procedure, which does not have a specific code to report. In this case, Medicare guidelines for reporting an unlisted procedure code was not followed. Specifically, when reporting an unlisted procedure code additional documentation to support the reason the unlisted code is being used, and the procedure the code is being reported for.  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 medical services coded 43499 have not been met. Therefore, we decided that the Plan does not have to pay for other procedures on the esophagus coded as 43499 provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive gastrointestinal (GI) panel provided on September 24, 2021.  

You asked the Plan to pay for the comprehensive GI panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was billed with the incorrect POS code.  

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the comprehensive GI panel have not been met. Specifically, this claim was submitted with the laboratory POS code while the documentation supports that the member's face-to-face service was rendered in an office setting. Additionally, the documentation submitted does not include any medical records to verify the medical necessity of this testing. Therefore, we decided that the Plan does not have to pay for the comprehensive gastrointestinal (GI) panel provided on September 24, 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 September 27, 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 September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (CPT code 90750) provided on October 25, 2021.  

You asked the Plan to pay for the shingles vaccine. You say that you were under the impression it was covered so you went with the clinic, versus the pharmacy. You state you did not realize it would not be covered. The Plan denied your request. The Plan says the shingles vaccine is a Part D drug in which is not a covered benefit under this medical plan.  

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.   

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (CPT code 90750) provided on October 25, 2021.   

Benefits for the shingles vaccine 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) with appliance to be provided by an OON provider.  

You asked the Plan to pre-approve pneumatic compression device. You say that other suppliers do not provide the needed equipment. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this device can be provided by an in-network supplier.  

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.   

The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) with appliance to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cystourethroscopy (52281) provided on July 16, 2021.  You asked the Plan to pay for the cystourethroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 52281 and 52601.  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 52281 is a column II code to column I code 52601. This code pair does not allow for 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 (52281) provided on July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vertebral corpectomy (63102 and 63103) and fluoroscopy (76000) provided on April 28, 2021.  You asked the Plan to pay for the vertebral corpectomy (63102 and 63103) and fluoroscopy (76000). You say that the services were rendered and are documented in the operative report. The Plan denied your request. The Plan says CPT codes 63102 and 63103 are not supported by the medical records and CPT code 76000 is considered inclusive to CPT code 22633.  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 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 vertebral corpectomy (63102 and 63103) and fluoroscopy (76000). Our reviewer says that this does not meet the criteria for reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that a partial or complete lumbar, single segment and each additional segment vertebral corpectomy (vertebral body resection) were performed. Our reviewer also says that CPT code 76000 is inclusive to CPT code 22633 as the medical records do not support billing CPT code 76000 as a distinct, separate procedure.  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 vertebral corpectomy (63102 and 63103) and fluoroscopy (76000) have not been met. Therefore, we decided that the Plan does not have to pay for the vertebral corpectomy (63102 and 63103) and fluoroscopy (76000) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prochlorperazine.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.    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 Prochlorperazine.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound care equipment (A6252, A6196, A6446, A6021) provided on May 11, 2021.  You asked the Plan to pay for the wound care equipment. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says separate payment is not made for services provided an inpatient stay.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.       Records show that the wound care equipment was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the wound care equipment (A6252, A6196, A6446, A6021) provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the angiography (75710) provided on January 12, 2021.  You asked the Plan to pay for the angiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 75710 and 37231.  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 75710 is angiography, extremity, unilateral, radiological supervision and interpretation.   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 angiography. Our reviewer says that CPT code 75710 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not support modifier -59 Distinct Procedural Service.  Procedure report documents an "Percutaneous endovascular intervention" performed,  an angiography would be necessary to perform the procedure documented, an therefore would not be covered separately.  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 angiography have not been met. Therefore, we decided that the Plan does not have to pay for the angiography (75710) provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee is unable to tolerate a lower level of care at this time. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services that have not been denied. The records do not show that the enrollee requires services at the LTACH that are not available at the current acute care 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from May 27, 2021, through June 8, 2021, billed with secondary diagnosis code J96.01.  You asked the Plan to pay for the inpatient hospital care as billed. You say that the medical documentation does not support the diagnosis as billed. The Plan denied your request. The Plan says the secondary diagnosis as billed is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as acute respiratory failure with hypoxia. 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 inpatient hospital care as billed. Our reviewer says that the documentation does not support the inpatient hospital care as billed. Our physician reviewer found the review indicates that the patient with history of dementia and hypertensive heart disease with heart failure presented to the emergency department via emergency medical services for evaluation of exertional dyspnea/shortness of breath and symptoms noted as moderate at that time. It was noted that his heart rhythm was irregular, with noted history of ischemic cardiomyopathy as well as chronic atrial fibrillation. Admission notes several recent admissions for atrial fibrillation, heart failure, and most recently an acute coronavirus infection (within a few weeks of current admission). He had been discharged at that time to home. However, because of worsening edema and shortness of breath he returned to the hospital. Although the physician confirmed an intended diagnosis of acute respiratory failure in the physician query, the remainder of the record did not clinically support this condition.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from May 27, 2021, through June 8, 2021, billed with secondary diagnosis code J96.01.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798) provided on August 27, 2020.  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 the services are not supported.  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 laboratory services have not been met. CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a office location, POS 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Nursing Facility Setting POS 32. Also, the laboratory results submitted indicate the specimen was collected on August 27, 2021 and received by the lab on August 28, 2021. Of note, the patient resides in Maryland (MD) and the billing laboratory is located in Arizona (AZ); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798) provided on August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Praluent.  You asked the Plan to pre-approve Praluent. You say that you recommend Praluent as a choice of treatment based on your experience with treating patients with elevated cholesterol and familial hypercholesterolemia. The Plan denied your request. The Plan says Praluent is a self-administered drug and does not fall under Part B coverage.  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 Praluent.  Benefits for Praluent 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for vascular study services (93976) provided on October 5, 2021.  You asked the Plan to pay for 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 with an appropriate modifier 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 vascular study services (93976) provided on October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablets.  You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 Eliquis tablets.   Benefits for self-administered 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.