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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 6, 
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 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 CPT code.  
In this case, the CPT Code Manual definition of code 43840 is "Gastrorrhaphy, suture of perforated duodenal 
or gastric ulcer, wound, or injury." 
 
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 services. Our reviewer says that  Our reviewer found an 
operative report was not provided to confirm or refute that CPT 43840 was or was not performed on 9/6/21. 
The emergency room note documentation that the enrollee still had a nasogastric tube (NGT), and some type of 
surgical intervention for treatment of a pre-pyloric duodenal ulcer, but there were insufficient medical records 
provided to comment on whether the correct CPT procedure code was or was not utilized. 
 
We looked at this coder's review, the file, and Medicare rules. The provider did not send enough information to 
verify their request for payment. 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 surgical services 
provided to the enrollee on September 6, 2021.
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 an intensive rehabilitation program is not medically necessary. 
 
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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are stable on outpatient medications with no issues that require a physicians evaluation three or more times per 
week. The records do not clarify why an intensive inpatient rehabilitation program is needed. The provided 
records do not explain why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate. Care at the skilled nursing facility level appears to be appropriate 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 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: 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. The Plan denied your request. The Plan says you do not 
require daily skilled nursing or therapy in a SNF setting. 
 
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 physician reviewer 
found that the most recent therapy documentation indicates that you are unable to ambulate. You require 
contact guard assistance for bed mobility and assistance for transfers. At the time of discharge from the 
inpatient rehabilitation facility you had stabilized medically and reached a new baseline level of function. You 
do not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. You are not 
expected to make measurable gains within a reasonable period of time, and do not require skilled therapy to 
prevent deterioration with mobility or self-care tasks. You do not require skilled therapy to establish a safe and 
effective maintenance program. Therefore, an admission to a skilled nursing facility for inpatient skilled 
services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 drug testing (G0480) provided on October 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that pre-authorization could not be completed as planned 
because of the laboratory being short-staffed. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services were not referred by a network provider or rendered in an in-
network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
 
 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 drug testing (G0480) provided on October 27, 
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 medical services provided to the enrollee on November 8, 
2021 and billed under code 99244. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare guidance says code 99244 has a status code of I and is excluded from 
payment on Medicare claims. Medicare uses another code for this service.  
 
The Plan must follow Medicare rules. Medicare rules say providers must report services correctly. In this case, 
this claim cannot be paid as billed due to the status indicator for code 99244. Therefore, we decided that the 
Plan does not have to pay for services provided on November 8, 2021 and billed under code 99244.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay (L3216). 
 
You asked the Plan to pre-approve foot orthotics. You say that these services should be covered on your 
benefits. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, 
depth inlay (L3216).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says you have not met the step therapy requirements. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the provided records do not indicate that you 
have has tried and failed the plan's preferred step one alternative or that you have a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on December 4, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this transport was both reasonable and medically necessary. The Plan denied your request. The Plan says the 
criteria for non-emergent ambulance transportation were not met. The Plan also says they did not see that the 
enrollee is unsafe sitting in a wheelchair, has behaviors that required continuous monitoring, or is a threat to 
themself or others. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation did not support that the 
ambulance transport on December 4, 2021 was medically reasonable and necessary for the patient. Our 
physician reviewer found the documentation did not support that other means of transport (such as stretcher 
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. Our 
reviewer also found that the documentation did not support that the patient needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on 
December 4, 2021. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on December 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health visits provided from September 14, 
2021, to November 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health visits. You say that the providers should have known 
they were out-of-network with Medicare offering services. The Plan denied your request. The Plan says you 
self-directed out-of-network. The Plan also says it is important to confirm with the Plan if a provider is in-
network with your plan before services are 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 outpatient mental health visits provided from 
September 14, 2021, to November 24, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone mass measurement (BMM) screening provided on 
July 13, 2021, reported with diagnosis code Z13.820. 
 
You asked the Plan to pay for the BMM screening as billed. You say that this was billed correctly and should 
be paid due to medical necessity. The Plan denied your request. The Plan says a valid diagnosis code was not 
billed on this claim. 
 The Plan must follow Medicare rules. Medicare rules say that claims for BMM screenings are denied when not 
billed with a valid diagnosis code as defined by the local contractor. 
 
Novitas, the local contractor for the State of Texas indicates the following diagnosis codes as valid for BMM 
screening claims: E21.0, E21.3, E23.0, E34.2, E89.40, E89.41, M80.08xA, M80.88xA, M84.58xA, M84.68xA, 
N95.8, N95.9, Q78.0, S34.3xxA, Z78.0, Z79.3, Z79.51, Z79.52, Z79.811, Z79.818, Z79.83, Z87.310. The 
billed code Z13.820 is not listed as a valid diagnosis. As such, this denial is supported by the Medicare billing 
rules. Therefore, we decided that the Plan does not have to pay for the bone mass measurement (BMM) 
screening provided on July 13, 2021, reported with diagnosis code Z13.820.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injection (64447) provided on 
September 27, 2021. 
 
You asked the Plan to pay for the anesthetic agent injection (64447). You say that procedure 64447 is a 
separately billable code according to coding guidelines and is not included in primary procedure. You say that 
anesthesia records to support the necessity are attached and the claim should be reprocessed for payment. The 
Plan denied your request. The Plan says CPT code 64447 is included in CPT code 01402 and cannot be 
separately reimbursed. 
 
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 64447 is a column II code to column I code 01402; however, 64447 
was billed with a modifier.  
 
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 anesthetic agent injection (64447). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the documentation does not support Medicare criteria for separate payment for post op pain management. 
The procedure report does not clearly document the injection was separate from anesthesia services provided. 
 
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 anesthetic agent injection (64447) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthetic agent injection (64447) provided on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, pelvic (nonobstetric), real time with image 
documentation; complete (76856) provided on January 19, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that service was billed appropriately and is supported in 
the record. The Plan denied your request. The Plan says this service is not supported as billed. The medical 
records show that a limited ultrasound (76857) was provided rather than a complete ultrasound. 
 
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 76856 is ultrasound, pelvic (nonobsteric), real time with image documentation; complete. 
 
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 ultrasound. Our reviewer says that this code is not 
appropriate for the service billed. Our reviewer found that the procedure report in this case does not include 
enough documentation to confirm a complete ultrasound was performed, to include visualization of the female 
pelvic organs and structure including the uterus, cervix, vagina, fallopian tubes and ovaries. The procedure 
report indicates that the right ovary was not visualized due to overlying bowel gas. In this case, a limited 
ultrasound is supported by the documentation submitted, rather than a complete ultrasound as billed. 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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound, pelvic (nonobstetric), real time with image documentation; complete (76856) 
provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (procedure code 01992) provided to the enrollee on 
November 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this code is bundled. 
 
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 01992 is "anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is 
performed by a different physician or other qualified health care professional); prone position." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the providers are in the same practice; 
however, they have different specialties performing different procedures. This service should be covered. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
anesthesia services (procedure code 01992) provided to the enrollee on November 2, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic (nonobstetric) ultrasound (76857) provided on 
July 16, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this service is supported in the record. The Plan 
denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) 
edit exists between 76775 and 76857. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. 
This service was not billed 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 76857 
is a column II code to column I code 76775. 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 the pelvic (nonobstetric) ultrasound (76857) provided on July 16, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the testing 
and you conducted it out of medical necessity. The Plan denied your request. The Plan says the rendering and 
referring providers are both out-of-network providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 laboratory services provided on December 9, 
2021, by an out-of-network (OON) provider.