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

We decided that the Plan does not have to pay for the abdomen x-ray (CPT code 74018-26) provided on April 19, 2022.

You asked the Plan to pay for the abdomen x-ray. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee was inpatient during this date of service.

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 abdomen x-ray have not been met. Review of the file shows that the enrollee was registered as an inpatient of a hospital; therefore, it is inappropriate to bill in an outpatient place of service on the appealed claim. Therefore, we decided that the Plan does not have to pay for the abdomen x-ray (CPT code 74018-26) provided on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81335 and 81355.

You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare guidelines.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) 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 code.


We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81335 and 81355.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code S9501 billed for date of service March 30, 2022 to April 3, 2022.

You asked the Plan to pay for procedure code S9501. You say that you disagree with the denial. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code.

We find that procedure code S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code S9501 billed for date of service March 30, 2022 to April 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes (81455) provided May 19, 2022.

You asked the Plan to pay for the Tempus xT assay. You say that this letter and attached documents support the medical necessity of the tests requested. The Plan denied your request. The Plan says the diagnosis submitted on the claim does not support medical necessity and is not covered per LCD Article.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The claim was billed with diagnosis code C83.31. This diagnosis code is not listed on Local Coverage Article Billing and Coding Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms A56867 under a ICD-10-CM diagnosis codes which are considered medically necessary for procedure code 81455.

 Based on this information, we decided that Medicare rules for coverage of the Tempus xT assay have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes (81455) provided May 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 1, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services (97026) provided from 
September 3, 2021, to October 8, 2021. 
 
You asked the Plan to pay for the infrared therapy services. You say that you would like this claim to be 
reconsidered for coverage. The Plan denied your request. The Plan says infrared therapy is considered not 
reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the infrared therapy services (97026) provided from September 3, 2021, to October 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the mental health services. You say that you would like to see an outside 
therapist. The Plan denied your request. The Plan says a network provider is available for necessary care. 
 
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 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on February 8, 2022. 
 You asked the Plan to pay for the services provided. You say that the services were coded according to medical 
records. The Plan denied your request. The Plan says the billed services were not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services provided on February 8, 
2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectropscopy (BIS) assessment using the ImpediMed L-Dex testing device.

You asked the Plan to pre-approve BIS assessment using the ImpediMed L-Dex testing device. You say that the requested services are medically necessary. The Plan denied your request. The Plan says there is no scientific research that documents the requested testing's long-term effectiveness and improvement on outcomes.

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 BIS assessment using the ImpediMed L-Dex testing device. Our reviewer says that BIS assessment using the ImpediMed L-Dex testing device is not considered medically reasonable and necessary in this case. Our physician reviewer found bioimpedance spectroscopy devices for detection of lymphedema are considered investigative and unproven.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BIS assessment using the ImpediMed L-Dex testing device have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectropscopy (BIS) assessment using the ImpediMed L-Dex testing device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational.

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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate the safety and effectiveness of the procedure.


 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on January 24, 2022.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim did not meet billing guidelines.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 


We find that CPT code 99070 has a status indicator of B, which means one or more edits present that cause the whole claim to be returned to the provider. 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 outpatient hospital services provided on January 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 21, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care services provided on January 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing care services. You say that the services were provided at the skilled 
nursing facility providing care to the enrollee. The Plan denied your request. The Plan says authorization was 
not obtained prior to 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 nursing care services provided on January 13, 
2022, by an out-of-network (OON) provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that these services are not medically necessary. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have skilled therapy needs; therefore, these services are 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 SNF care have not been met. 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 a telehealth visit provided on April 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that prior authorization is not required, and you 
request this claim be reprocessed and paid. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider. 
 
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 a telehealth visit provided on April 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta Suser vial 32 mg. 
 
You asked the Plan to pre-approve Zilretta Suser vial. You say that the records provided support the necessity 
of the service. The Plan denied your request. The Plan says the information provided did not meet the 
requirements for covering this drug. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Zilretta Suser Vial 32 mg have been 
met. the records show that the Plan made multiple attempts to obtain needed records and additional information 
from the provider without success. Therefore, we decided that the Plan does not have to pre-approve Zilretta 
Suser vial 32 mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 4, 2022.

You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the DME was billed with the incorrect place of service.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel (CPT code(s): 81355, 81230, 0033U) provided on March 25, 2022.

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 clinical value and effectiveness of comprehensive pharmacogenetic testing have not been demonstrated in the peer-reviewed literature.

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 laboratory services. Our physician reviewer found the review has determined that the clinical value and effectiveness of comprehensive pharmacogenetic testing has not been demonstrated in peer reviewed literature. There is no specific clinical rationale for the requested testing. Additionally, this testing is not considered a covered screening service per the Medicare Benefit Policy Manual, Chapter 15, Section 280. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.

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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel (CPT code(s): 81355, 81230, 0033U) provided on March 25, 2022.
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 the enrollee requires LTACH services 
for their medical management and a lower level of care won't meet the enrollee's medical needs. The Plan 
denied your request. The Plan says the Medicare criteria for LTACH admission were not met and the enrollee's 
needs are currently being met at the level of care they are at. 
 
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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shingles vaccine provided on June 17, 2022. 
 
You asked the Plan to pre-approve the vaccine. You say that your doctor did not tell you what the cost was. 
You also say that you figured it was covered by your insurance. The Plan denied your request. The Plan says 
the shingles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the 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 vaccine. 
Therefore, we decided that the Plan does not have to pre-approve the shingles vaccine provided on June 17, 
2022.  
 
Benefits for the 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.