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

 
We decided that the Plan does not have to pre-approve an out-of-network referral for surgery and tissue exam. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a participating provider available 
 
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 
an out-of-network referral for surgery and tissue exam.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99212, 92134, 66821 billed for date of 
service October 13, 2022. 
 
You asked the Plan to pay for procedure codes 99212, 92134, 66821. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 99212 is bundled into payment for code 
66821. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99212 
is a column II code to column I code 66821. This claim has not been billed with an appropriate modifier to 
bypass the edit. 
 
The rules say that specific diagnosis codes are covered when billed with code 92134. Diagnosis code H26.493 
(Other secondary cataract, bilateral) is not on the list of approved diagnoses for this procedure code). 
 
Code 66821 was not billed with an anatomical modifier appended. This code is not payable as billed. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99212, 92134, 66821 billed for date of service October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a clinical trial at an out-of-plan provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says services related to clinical trials are covered by Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve a referral to a provider to start a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve a referral for a clinical trial at an out-of-plan provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service December 7, 
2022. 
 You asked the Plan to pay for procedure code 88342. The Plan denied your request. The Plan says payment for 
code 88342 is bundled into payment for code 88184. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88342 
is a column II code to column I code 88184. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 88342 billed for date of 
service December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for too long and has failed conservative approaches to treatment. You say that this treatment is 
considered safe and effective, and the necessary coverage should be provided. The Plan denied your request. 
The Plan says there are not enough studies to show that Vertiflex Superion is safe and effective to treat back 
pain. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental, and more research is needed.  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication of enrollment in a clinical trial for this device. 
 
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 device. 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 enrollees 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 11, 2022, to July 
10, 2022. 
 You asked the Plan to pay for the home health services. You say that even though the NOA was filed late, you 
appended the KX modifier.  You believe this should grant you an exception to the timely filing rule. 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 June 11, 2022. The NOA was not received by the Plan until September 20, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. 
 
In addition, while it is true that the KX modifier can indicate an exception to the timely filing requirements for 
a NOA, the supporting documentation provided by the provider MUST prove that the exception is being 
requested due to a reason beyond the home health agency's control.  No such evidence has been provided by 
your organization, and the burden is on the home health agency to prove why an exception should be granted.  
Just appending the KX modifier is not sufficient. If you wish to supply supporting documentation as to why an 
exception should be granted, you need to provide that to the health plan directly. Therefore, we decided that the 
Plan does not have to pay for home health services provided from June 11, 2022, to July 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 home ventilator. 
 
You asked the Plan to pre-approve the Life2000 home ventilator. You say that the patient has been hospitalized 
on chronic steroids. She felt great benefit from using the Life2000 device and it improved her functional 
capacity. The Plan denied your request. The Plan says the requested Life2000 is not medically necessary. The 
Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support. It is 
designed primarily for use during activity. There is insufficient evidence of benefit in the treatment of the 
patient's COPD/emphysema, and no documentation that the patient has failed a continuous positive airway 
pressure (CPAP) or bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
 
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 Life2000 home ventilator. Our 
reviewer says that the Life2000 home ventilator is not medically necessary. Our physician reviewer found the 
enrollee is a 66 year old female with a diagnosis of chronic obstructive pulmonary disease (COPD)/ 
emphysema, pulmonary fibrosis, alcoholic cirrhosis, recent tobacco abuse (quit November 2022), and 
hypertension. She uses home oxygen. The record does not provide any specific documentation demonstrating 
that she has failed a BiPAP when at her baseline breathing. 
 
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 Life2000 home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Life2000 home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (81518) provided on September 15, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (81518) 
provided on September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia billed with code J3490 for date of service 
March 13, 2023. 
 
You asked the Plan to pay for code J3490. You say that code J3490 was a medically necessary part of this 
patient's treatment and separate expenses are incurred for this medication. The Plan denied your request. The 
Plan says separate payment cannot be made for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that if performed to facilitate an injection, the use of 
local anesthesia is included in the global surgery payment and is not separately billable.  
 
In this case, the patient underwent a knee joint injection (code 20610-50).  As part of the surgery, the provider 
also provided local anesthetic.  This anesthetic was billed with code J3490. Medicare rules are clear that no 
separate payment is made for local anesthetic, regardless of the expense incurred.  You did not bill this drug 
with a modifier to indicate it was separate and distinct from the procedure itself, so no separate payment can be 
made.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for local 
anesthesia billed with code J3490 for date of service March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) provided August 
15, 2022, to September 6, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device (E0675) provided August 15, 2022, to September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99305) rendered 
on November 1, 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 Current Procedural Terminology (CPT) code 99305 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 99305 is "Initial nursing facility 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, 35 minutes are spent at the bedside and on the patient's 
facility 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 not supported by the medical records. Our reviewer found that the review has determined that 
the records did not support either a comprehensive history or a comprehensive examination. 
 
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 initial nursing facility care (procedure code 99305) rendered on November 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 9, 2022, to 
February 7, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA and 
corrected the admission date on the claim. 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, 2022. The NOA was not received by the Plan until March 10, 
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 9, 2022, to February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services rendered on January 19, 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 are not supported. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider has not sent in a valid physician order for these services. The order sent in is for a different patient.. 
Therefore, we decided that the Plan does not have to pay for drug testing services rendered on January 19, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The provided records document that the home ventilator is being requested for use in a 
pressure support with safety tidal volume mode which could be provided by a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. The provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. The provided 
records in this case do not provide adequate detailed information to meet Medicare criteria for coverage of a 
ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. Therefore, the enrollee does not meet 
criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on December 
21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level MBB provided on August 19, 2022.  
 
You asked the Plan to pay for a third level MBB. You say that you are requesting reconsideration of the denied 
injection. The Plan denied your request. The Plan says that the third level MBB was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are limited to two levels per 
session unless there are unique circumstances requiring a third or fourth level. 
 
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 a third level MBB. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the LCD limits diagnostic MBBs to 
two levels per session. There was no extraordinary circumstance documented. Therefore, the third level MBB 
was not medically reasonable and 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 a third level MBB have not been met. Therefore, we decided that the Plan does 
not have to pay for a third level MBB provided on August 19, 2022.