Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 15, 2023, to 
April 12, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe you submitted the NOA 
timely. 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 March 14, 2023. The NOA was not received by the Plan until June 20, 
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 March 15, 2023, to April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplies (B4185, B4193, B4220, B4224) provided 
on April 29, 2023 to May 4, 2023. 
 
You asked the Plan to pay for the nutritional supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. There was not an 
itemized delivery receipt for the date of service billed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for nutritional supplies (B4185, B4193, B4220, B4224) provided on April 29, 2023 to May 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 12, 2022, to August 26, 2022, billed with code CDXF1. 
 You asked the Plan to pay for the SNF services as billed. You say that the records were sent, and the claim 
should be paid.  The Plan denied your request. The Plan says the appeal request submitted did not include 
medical records for the enrollee from this stay. Without medical records, the billed HIPPS code cannot be 
confirmed.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The file does not include full medical records for the SNF stay at 
issue and does not include the completed Minimal Data Set form to justify the HIPPS code billed. Based on 
this information, we decided that there is insufficient information in the record to determine if Medicare rules 
for coverage of the SNF services as billed have been met.  Therefore, we decided that the Plan does not have to 
pay for the skilled nursing facility (SNF) services provided from August 12, 2022, to August 26, 2022, billed 
with code CDXF1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous insulin treatment (OIVIT) 
provided on April 10, 2023.  
 
You asked the Plan to pay for the OIVIT services. You say that the services rendered should be paid.  The Plan 
denied your request. The Plan says the services are not billed correctly and are not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT treatments are nationally noncovered by 
Medicare.  Therefore, we decided that the Plan does not have to pay for the outpatient intravenous insulin 
treatment (OIVIT) provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  practitioner services provided on September 28, 2022, billed with 
procedure code 64624. 
 
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 payment for this service is bundled into 
payment of another service. 
 
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. We find that the denial rationale provided by the Plan is not supported. The Plan 
states that payment for code 64624 is bundled into payment of another service. However, the Plan did not 
provide proof that any payment was made. As such, the Plan has not given a valid reason to support their 
denial. Therefore, we decided that the Plan has to pay for  practitioner services provided on September 28, 
2022, billed with procedure code 64624.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36215 and 75710 rendered on April 24, 
2023. 
 
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 records do not support the services. 
 
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  is "CPT 36215: 
 
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a 
vascular family 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation." 
 
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 not supported by the medical records. Our reviewer found that the documentation does not 
support coverage of the codes in question. The enrollee underwent a fistulogram and balloon angioplasty that 
was coded and covered as CPT 36902. This code includes imaging of the area around the 
anastomosis. Therefore, coding for vessel selection and upper extremity angiography is not separately 
billable.  Additionally, the documentation of upper extremity angiographic details is insufficient to justify 
coding for an upper extremity angiogram in addition to the fistulogram. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36215 and 75710 rendered on April 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy, soft tissue of forearm and/or wrist; superficial 
rendered on February 27, 2023. 
 
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 there are not enough detailed procedure notes to determine the clinical utility of the services 
performed. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was seen for wound management for a skin tear wound of the right, medial, second 
finger for 5 days. Removal of infected tissue (surgical excisional debridement), Santyl, alginate calcium, gauze 
was planned. Biopsy of this wound area was taken. However, there was no explanation in the provided 
documentation to support performing a biopsy of this simple skin tear. There was no description of 
abnormalities suggesting cancer or other condition related to the skin tear wound that wound warrant biopsy. 
Therefore, without sufficient support made for this request, the biopsy will be considered not medically 
necessary at this time.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for biopsy, soft tissue of forearm and/or wrist; superficial rendered on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for 
date of service March 16, 2023. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed codes are 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. 
 
We find that outpatient intravenous insulin therapy, billed with CPT code 96365 and 96366, is not a covered 
Medicare benefit. We find that orders were placed for code 96521. However, the records do not show that the 
refilling and maintenance of a portable pump was provided. We find that there is a more accurate code 
available that describe the injection services billed with code J1817. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36556 and 76937 rendered on May 16, 
2023. 
 
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 denied codes remain 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 the denied codes is: 
 
CPT 36556: 
 
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 
 CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
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 not supported by the medical records. Our reviewer found that in its current form, the 
documentation does not support that the services in question were rendered. No procedure note was included in 
the records provided to determine if a central line with ultrasound guidance was performed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 36556 and 76937 rendered on May 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 30, 2022, to 
December 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was filed timely. 
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 November 30, 2022. The NOA was not received by the Plan until January 
12, 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 November 30, 2022, to December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A5500 and A5512 for date of service February 16, 
2023. 
 
You asked the Plan to pay for codes A5500 and A5512. You say that you disagree with the Plan's denial The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Review of the file shows that the documentation did not include 
documentation of the specific durable medical equipment being requested. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for codes A5500 and A5512 for date of service February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a cleaning (D1110) provided on June 20, 2023. 
 
You asked the Plan to pay for the cleaning. You say that you were due for a cleaning and it was denied 
incorrectly. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. The rules say that Medicare health plans must disclose benefit limitations in clear accurate 
terms. The Plan contract does not clearly disclose the benefit limitations for cleanings. The Evidence of 
Coverage does not clearly disclose that you can get two cleanings at any point in one calendar year, or if the 
cleanings have to be six months part. 
 
The Plan has not disclosed in clear accurate terms, the benefits offered, including applicable conditions and 
limitations. Therefore, we decided that the Plan has to pay for a cleaning (D1110) provided on June 20, 2023.  
 
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: Favorable

 
We decided that the Plan has to pay for the services (93503, 76937) provided on October 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed codes 
are 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 93503 is "Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes". 
The CPT Code Manual definition of code 76937 is "Ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime 
ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in 
addition to code for primary procedure)". 
 
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 use of code 93503 
and 76937 is not supported by the records provided. Our reviewer found that there is documentation of 
insertion and placement of flow directed catheter for monitoring purposes, so code 93503 is supported. There is 
also documentation of ultrasound guidance for vascular access, so code 76937 is supported. 
 
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 
the services (93503, 76937) provided on October 26, 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.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve surgical access to an implant body. You say that you already had one part 
done and need the rest finished. The Plan denied your request. The Plan says that this service must be 
performed between 3 to 6 months after the implant placement (D6010). 
 
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. Specifically, the Plan says this service must be performed between 3 to 6 months 
after the implant placement (D6010). The Plan has already pre-approved the initial implant placement and has 
not submitted documentation supporting the 6-month requirement. This means that the second stage must be 
pre-approved but will only be covered when an appropriate amount of time has passed after the first stage of 
the procedure. 
 
 Therefore, we decided that the Plan has to pre-approve surgical access to an implant body (D6011).  
 
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: Favorable

 
We decided that the Plan has to pay for evaluation and management services (procedure code 99222) rendered 
on December 14, 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 that Current Procedural Terminology (CPT) code 99222-25 (1 units) remains 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 99222 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 that this appears to be coded appropriately 
with moderate level of complexity and with appropriate documentation. 
 
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 
evaluation and management services (procedure code 99222) rendered on December 14, 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2023, billed with 
multiple codes.  
 
You asked the Plan to pay for the genetic testing billed. You say that this was necessary testing and should be 
paid.  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 a panel evaluating multiple pathogen genes through NGS 
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 April 4, 2023, billed with multiple codes.