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

 
We decided that the Plan does not have to pay for the Guidance UTI panel provided on April 3, 2023. 
 
You asked the Plan to pay for the Guidance UTI. You say that this testing should be covered. The Plan denied 
your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the Guidance UTI have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guidance UTI panel provided on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
March 6, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 83520 and 87798. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found the laboratory report includes 
documentation of stool testing; however, there is insufficient documentation to confirm test being reported with "not otherwise specified" procedure codes. These services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service March 6, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nivestym. 
 You asked the Plan to pre-approve Nivestym. You say that Nivestym is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Nivestym have not been met. 
 
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 Nivestym. Our reviewer says that 
treatment with Nivestym is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Udenyca, Zarxio, Fulphila, Neulasta OnPro and/or Ziextenzo before they will 
approve the requested drug. The enrollee has neutropenia in the setting of chemotherapy. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivestym have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Nivestym.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 22, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
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 laboratory services was not filed until April 19, 2023. 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 the laboratory services provided on January 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483).  
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says ordering a multi-class 
panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds the needs 
of the enrollee.  
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered when the criteria in 
the rules section of this letter are met. 
 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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
enrollee did not have unexpected results from a urine screening panel or history suggestive of likely 
abuse/misuse of multiple medications to justify the 22+ drug class confirmation testing. The enrollee did not 
require all drug classes tested. The LCD criteria was not met.  
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional speech therapy services. 
 
  You asked the Plan to pre-approve the therapy services. You say that the enrollee requires additional speech 
therapy due to their progressive medical condition. The Plan denied your request. The Plan says the enrollee 
has already completed 44 speech therapy visits and additional care can be provided in a home program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollee's medical condition. The enrollee has previously been treated with 
outpatient therapies and should be independent with a home program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional speech therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 8, 2022, billed 
with codes 87481, 87798 x13. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are appealing with the attached 
medical records. Kindly review and process the claim further. The Plan denied your request. The Plan says 
panel testing should be billed using one CPT code on the claim. 
 
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 
November 8, 2022, billed with codes 87481, 87798 x13.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 9, 2023, to 
February 7, 2023. 
 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 January 9, 2023. The NOA was not received by the Plan until March 23, 
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 January 9, 2023, to February 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided on May 7, 
2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you do not feel that you should 
have to pay for a service that was not filed with the insurance company in a timely manner by the provider 
and/or incorrectly. The Plan denied your request. The Plan says you received services from an OON provider. 
The Plan also says the provider is billing you for the denied amount, and did not agree to stop billing you at this 
time. 
 
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 emergency department visit was not filed until April 19, 2023. 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 the emergency department visit (99284) provided 
on May 7, 2020.  
 Please Note: you may contact your Centers for Medicare & Medicaid Services (CMS) regional office for 
questions or assistance regarding a Medicare participating provider. Your CMS regional office is located in 
New York and their phone number is 212-616-2222.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 20, 2023, billed 
with codes 81225, 81226, 81227, and 81232. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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. The panel testing was not billed with a single 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 February 20, 
2023, billed with codes 81225, 81226, 81227, and 81232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97016 and 99203 as well as a compound 
medication (J1955, J3411, J3415, J3420) billed for date of service September 1, 2022. 
 
You asked the Plan to pay for procedure codes 97016 and 99203 and a compound medication. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says the provided records do 
not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99203 is: Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 30-44 minutes of 
total time is spent on the date of the encounter.   
The definition of code 97016 is: Application of a modality to 1 or more areas; vasopneumatic devices. 
 
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 procedure codes 97016 and 99203 and a compound 
medication. Our reviewer says that procedure codes 97016 and 99203 and a compound medication do not meet 
criteria for payment as billed. Our reviewer found that the provided documentation is insufficient to confirm a 
new or established patient. The medical record does not include documentation to verify patient status and 
therefore procedure code 99203 cannot be verified. The procedure report does not include documentation of 
application of a vasopneumatic device. Procedure code 97016 was not found in medical record and therefore 
cannot be verified. Finally, the medical record describes the compounded medications given; in this case, there 
is a more appropriate code to report for service documented, as mixed/blended medications are not reported 
separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 97016 and 99203 and a compound medication have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 97016 and 99203 as well as 
a compound medication (J1955, J3411, J3415, J3420) billed for date of service September 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on November 22, 2022, to November 28, 
2022, billed with procedure code A4222-SH. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
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 A4222-SH is infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately). 
 
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 practitioner services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the record shows that the supplies in 
question were ordered and shipped to the enrollee. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on November 22, 2022, to November 28, 2022, billed with 
procedure code A4222-SH.  
 
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 procedure code 99291 billed for dates of service from 
January 1, 2023, to January 8, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided medical records do not support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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. Specifically, the available medical records do not address the span of time required to render the services at issue. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99291 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99291 billed for dates of service from January 1, 2023, to 
January 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiology office visit provided on March 17, 2023. 
 
You asked the Plan to pay for a cardiology office visit. You say that this was medically necessary and should 
be covered. 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 cardiology office visit 
provided on March 17, 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 the IRF care. You say that the IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. 
 
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 the 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF as 
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 the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arm compression sleeve. 
 
You asked the Plan to pre-approve an arm compression sleeve. You say that the requested compression sleeve 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the request does not meet 
Medicare criteria. 
 
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 an arm compression sleeve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a Pancoast tumor status surgery/chemo/radiation with more 
recent evidence of metastases in the brain. It was reported that the enrollee had left hand neuropathic pain and 
headaches. However, the provided documentation did not clearly show evidence of lymphedema extending to 
the chest/trunk/abdomen as required of this particular compression sleeve. Therefore, an arm compression 
sleeve will be considered not medically necessary for this enrollees conditions.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an arm compression sleeve have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an arm compression sleeve.