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

 
We decided that the Plan does not have to pay for arthroscopic shoulder debridement (29823) provided May 7, 
2021. 
 
You asked the Plan to pay for the surgical procedure. You say that the claim has been denied as exceeding the 
limit for timely filing and you ask for reconsideration of the attached claim for payment. The Plan denied your 
request. The Plan says the claim was received after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the surgical procedure was not filed until May 20, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for arthroscopic shoulder debridement (29823) provided May 7, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 7, 2022, to 
February 4, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 7, 2022. The NOA was not received by the Plan until August 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 7, 2022, to February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  SelectMDx (0339U) provided January 11, 2023. 
 
You asked the Plan to pay for  the laboratory service. You say that you are asking for this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says SelectMDx is not a covered benefit 
because this is not a test which has met the coverage criteria. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  SelectMDx (0339U) provided January 11, 2023.
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 the enrollee can only ambulate short distances and 
requires close monitoring, rehab services will help his function and independence. The Plan denied your 
request. The Plan says the enrollee does not meet all the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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 SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the admission to a SNF is 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 that the enrollee does not require daily skilled nursing and/or skilled therapy services. 
The enrollee is medically stable and can receive further rehabilitation services 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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the anti-cancer drug, Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the requested anti-cancer drug is medically necessary. 
The Plan denied your request. The Plan says coverage for the requested drug does not meet medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Imfinzi. Our reviewer says that the 
requested drug, Imfinzi, does not meet the criteria for approval. Our physician reviewer found Imfinzi, as a 
single agent, is not indicated for metastatic disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the anti-cancer drug, Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for December 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with diagnosis codes that 
exclude each other. 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 pay for procedure code 99233 billed 
for December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 billed for November 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99442 is 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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the enrollee was seen by the same provider for an office visit billed with code 99214 on November 17, 2022 for a related diagnosis. 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 pay for procedure code 99442 billed for November 17, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing billed with code 81455 for date of service 
March 24, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered for the patient's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a 
diagnostic laboratory test is reasonable and necessary when the patient has either recurrent, relapsed, refractory, 
metastatic, or advanced stage III or IV cancer 
 
In this case, the testing at issue was not ordered as part of a plan of care for a patient with cancer.  Rather, this 
testing was ordered solely based on a diagnosis of anemia, which is not a covered diagnosis under the rule. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing billed with code 81455 for date of service March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hyaluronan or Derivative, Synvisc or Synvisc-One, 
For Intra-Articular Injection (J7325). 
 
You asked the Plan to pre-approve an injection. 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. 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 an injection have been met. Specifically, medical records were requested but not received. Medical necessity cannot be established without 
this information. Therefore, we decided that the Plan does not have to pre-approve a Hyaluronan or Derivative, 
Synvisc or Synvisc-One, For Intra-Articular Injection (J7325).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are learning how to walk and take care of 
yourself again. The Plan denied your request. The Plan says that SNF care was no longer 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 that as of the last covered day, you did not require daily skilled nursing or 
rehabilitation services. You did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, you did not require any skilled services on an inpatient basis, at a skilled level 
of care as of May 26, 2023. Your function was at or near your baseline level and could be discharged to a lower 
level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service September 
15, 2022.  
 
You asked the Plan to pay for procedure code A0425. You say that the patient was transported to the nearest 
facility accepting patients.  This was a super rural area and closer facilities were all full. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed on a single claim line.  
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value on a single claim line cannot be paid when the MAI value is 1.  
 
In this case, the MUE for a single claim line for CPT code A0425 is 250. The MAI value for this code is 1. You 
billed 257 units of this code on a single claim line, exceeding the MUE. Based on this information, we decided 
that Medicare rules for coverage of procedure code A0425 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A0425 billed for date of service September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS heart failure (HF) system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this should only be approved for patients enrolled in a clinical trial. 
 
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 the system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management.  
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS heart failure (HF) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (procedure code G0482) rendered on November 
17, 2022. 
 
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 documentation does not support 15-21 drug classes being tested; only 8 classes were tested. 
 
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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, this code requires 
documentation for testing of 15-21 drug classes. The records only support 8 classes. 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 drug testing (procedure code G0482) rendered on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing billed for code 0012M for date of service 
December 27, 2022. 
 
You asked the Plan to pay for code 0012M. You say that this testing was medically necessary and provides 
actionable results that can make a meaningful difference in the diagnosis and treatment of the patient. The Plan 
denied your request. The Plan says CxBladder testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is non-covered. This non-
coverage rule applies regardless of appropriateness or medical necessity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 0012M have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing billed for code 0012M for date of service December 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 9, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this claim needs to be reprocessed. The 
Plan denied your request. The Plan says you billed these services with an inappropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate diagnosis 
codes for services.  In this case, you only billed one diagnosis code on this claim: Z99.3 (dependence on 
wheelchair).  However, this is not a code that should be billed alone.  The code's definition says that this code 
requires 'code first' logic, meaning that the cause of the wheelchair dependence must be coded before adding 
the diagnosis of Z99.3 to the claim.  You have not billed with a diagnosis to indicate the cause of the 
wheelchair dependence. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 12, 2022. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis code billed is payable. The Plan 
denied your request. The Plan says you billed with an incorrect pair of diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that ICD-10 codes with an Excludes1 note indicate it 
is a pure excludes note. An Excludes1 note indicates that the code excluded should never be used at the same 
time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together.  
 
In this case, you billed the services at issue with diagnosis codes of E87.1, E22.2, and E86.9. Code E87.1 has 
an Excludes1 relationship with diagnosis code E22.2, so these two codes cannot be billed together. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on December 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided do not demonstrate 
that the enrollee meets criteria for either AD or FTD. Other potential causes of cognitive impairment have not 
been ruled out. 
 
 
  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 PET scan have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on December 19, 2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that this provider is certified to provide 
opioid treatment services. The Plan denied your request. The Plan says that the claim was billed by the provider 
and not the facility.  These services must be billed by the facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services provided on December 19, 2022.  
 
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.