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

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99283 
for December 31, 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 payment is included in the global surgical payment. 
 
The Plan must follow Medicare rules. The rules say that follow-up visits during the postoperative period of the 
surgery that are related to recovery from the surgery are included in the global surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99283 was related to and billed within 90 days of 
major surgical procedure 25605 billed on December 26, 2022. Payment for code 99283 is included in the 
global surgical payment for code 25605. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services billed with code 99283 for December 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 11, 2022, 
to September 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 11, 2022, to 
September 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 2, 2022, to 
September 16, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
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 September 2, 20222. The NOA was not received by the Plan until October 
5, 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 September 2, 2022, to September 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 30, 2022, through 
August 18, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
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 July 30, 2022. The NOA was not received by the Plan until January 11, 
2023. 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 July 30, 2022, through August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ThermiVa. 
 
You asked the Plan to pre-approve the ThermiVa. You say that the ThermiVa is medically necessary. The Plan 
denied your request. The Plan says the ThermiVa is not covered by Medicare or by the Plan. 
 
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 ThermiVa. Our reviewer says that 
the requested ThermiVa is not considered medically reasonable and necessary. Our physician reviewer found 
that in this case, the record indicates that you have rectocele and cystocele. There is insufficient literature to 
support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. 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 ThermiVa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ThermiVa.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a short-latency somatosensory study provided on April 20, 
2022. 
 
You asked the Plan to pay for a short-latency somatosensory study. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a short-latency 
somatosensory study provided on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 26, 2021, to 
November 1, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of secondary diagnosis code G92.8. The Plan denied your request. The Plan 
says the medical records do not support the billing of secondary diagnosis code G92.8. 
 
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 G92.8. 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 services at the DRG originally billed. Our reviewer says 
that the medical records do not support the billing of secondary diagnosis code G92.8. Our physician reviewer 
found toxic encephalopathy refers to encephalopathy from exposure to a toxin. The enrollee did not have this 
clinical scenario. He had delirium which is different and has a different diagnosis code.  
 
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 inpatient hospital services provided on October 26, 2021, to November 1, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 96372 billed for date of service February 
26, 2023. 
 
You asked the Plan to pay for codes 93005 and 96372. You say that these services were medically necessary 
and provided in good faith. The Plan denied your request. The Plan says these codes are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, meaning that they are STV-packaged services.  The disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005 and 96372 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 93005 and 96372 billed for date of service February 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hepatic function panel (80076) provided on December 9, 
2021.  
You asked the Plan to pay for the hepatic function panel. The Plan denied your request. The Plan says this test 
is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the hepatic function panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the hepatic function panel (80076) provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted case management provided on February 14, 2023. 
 
You asked the Plan to pay for targeted case management. You say that you were told by the provider that your 
insurance would cover the expenses. The Plan denied your request. The Plan says the services are not covered 
by Medicare or by the Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for targeted case management provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you are the sole providers of this test. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cranial radiation therapy to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve cranial radiation therapy to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
cranial radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 9 units of procedure code 88177 billed for date of service 
March 3, 2023. 
 
You asked the Plan to pay for procedure code 88177. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88177 is 6. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. 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 procedure code 
88177. Our reviewer says that procedure code 88177 does not meet criteria for payment. Our physician 
reviewer found that there is no documentation as to whether 9 units of 88117 were rendered or why 9 units 
would be medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 88177 
have not been met. Therefore, we decided that the Plan does not have to pay for 9 units of procedure code 
88177 billed for date of service March 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on February 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby services provided on December 8, 2022, billed 
with code 99360. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that payment should be made for 
code 99360. The Plan denied your request. The Plan says this service is not paid by Medicare.  
  
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made to physicians for standby 
services. Such services are included in facility payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay 
for the standby services provided on December 8, 2022, billed with code 99360.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay (0108U) 
provided on February 2, 2023.  
 
You asked the Plan to pay for the TissueCypher Barrett's esophagus assay. You say that the enrollee's treating 
physician ordered this test with the intent to use the results to provide a risk score and risk class that are 
correlated with risk of progression to esophageal adenocarcinoma. The Plan denied your request. The Plan says 
the clinical value and effectiveness of TissueCypher Barrett's esophagus assay have not been demonstrated in 
the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the TissueCypher Barrett's esophagus assay. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that TissueCypher testing is not standard of care as per national clinical 
guidelines and 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 the TissueCypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay (0108U) provided on 
February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 8, 2022, to June 
6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that a system issue with your 
electronic claim vendor caused the date of admission to be incorrect on the claim. The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 8, 2022, to June 6, 
2022.  
 
Please note that you indicated in additional information you submitted to us that you have discovered the 
billing issue with the admission date on the claim and have submitted a corrected claim.  This corrected claim 
has not, to our knowledge, been received or adjudicated by the Plan.  Please contact the Plan directly regarding 
the submission of your corrected claim.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on August 31, 2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file does not contain any documentation to support the HIPPS 
code as billed. 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 the home health services rendered 
on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (nivolumab) for use with doxorubicin, 
vinblastine, and dacarbazine. 
 
You asked the Plan to pre-approve the requested treatment with Opdivo. You say that it is felt that this should 
be allowed as the enrollee cannot tolerate standard treatment regimens. The Plan denied your request. The Plan 
says this is not medically indicated for the enrollee's condition. 
 
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 the requested treatment with Opdivo. 
Our reviewer says that the requested treatment is not shown to be medically reasonable and necessary in this case.  Our physician reviewer found the record indicates that the enrollee has a diagnosis of Hodgkin's 
Lymphoma. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare-approved cancer drug compendia do not contain a supportive citation for 
the use of the requested drug in the enrollee's clinical situation.  No literature from Medicare approved cancer 
journals were submitted for review. The elements of the coverage criteria are not satisfied. 
 
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 requested treatment with Opdivo have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Opdivo (nivolumab) for use with doxorubicin, vinblastine, and 
dacarbazine.