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 January 12, 2022, to 
February 10, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 12, 2022. The NOA was not received by the Plan until June 28, 
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 12, 2022, to February 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 22, 2021, to 
December 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you have correctly billed the services at issue. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that the following case mix variables are obtained from 
home health or other Medicare claims: 
 
1. Admission Source  Institutional (i.e., acute hospital, inpatient rehabilitation facility, skilled nursing facility, 
long-term care hospital, inpatient psychiatric facility) or Community 
2. Timing  Early (the first 30-day period of care) or Late (all subsequent 30-day periods of care, unless there is 
a gap of more than 60-day between the end of one period of care and the start of another) 
3. Clinical Group  As determined by the principal diagnosis reported on home health claims; 30-day periods 
are assigned to one of 12 clinical groups describing the primary reason for the home health encounter 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim at issue has been reported as an 
institutional admission source. The case record does not support that the enrollee was admitted as an inpatient 
immediately prior to the rendering of the home health services at issue. Reporting of an institutional admission 
source does not appear to be appropriate for the claim in dispute. Therefore, we decided that the Plan does not 
have to pay for home health services provided from November 22, 2021, to December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
1, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the outpatient mental health and infusion therapy 
services coded as 90834, 96365, 90837, J2405, J3475, 96375 and J3490 provided on April 4, 2022, to April 20, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the outpatient services. You say that you are requesting 
reimbursement of depression and pain treatment you received. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to reimburse you for the outpatient mental health and 
infusion therapy services coded as 90834, 96365, 90837, J2405, J3475, 96375 and J3490 provided on April 4, 
2022, to April 20, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic foot care procedures (11057, 11721) provided on 
December 13, 2022. 
 
You asked the Plan to pay for diabetic foot care. You say that you have correctly billed the services at issue. 
The Plan denied your request. The Plan says the services at issue have been billed without a modifier necessary 
for separate payment. 
 The Plan must follow Medicare rules. Medicare rules do not allow separate payment for an additional 
procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure 
and if billed without modifier -58, -78, or -79. 
 
We looked at the file and Medicare rules. In this case, the services at issue have a global surgery fee period. 
The case record documents that the services at issue were furnished during the postoperative period of a prior 
procedure. The services at issue were not billed with the necessary modifiers. Based on this information, we 
decided that Medicare rules for coverage of diabetic foot care have not been met. Therefore, we decided that 
the Plan does not have to pay for diabetic foot care procedures (11057, 11721) provided on December 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bridge for tooth numbers 3-6 (D6242, D6752 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you need a bridge because chewing is 
painful. The Plan denied your request. The Plan says the request is medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. The Plan limits bridges to cases where only 
one upper anterior tooth or two lower anterior teeth are missing. With no missing posterior teeth.  
 
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 dental services. Our reviewer says 
that the criteria for fixed bridges has not been met. Our physician reviewer found that in this case a posterior 
tooth is missing, and there are no missing anterior teeth. Additionally, due to the poor condition of the 
abutments, a long span bridge from tooth number 3-6 would not be considered medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bridge for tooth numbers 3-6 (D6242, D6752 x 3).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 You asked the Plan to pre-approve Stelara. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Stelara. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Entyvio, Inflectra or Remicade would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 12, 2019, to 
March 15, 2019. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the review concluded that a change from DRG 
871 to DRG 872 was needed. 
 
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was alert and oriented and did not have any signs or symptoms supporting organ failure 
directly related to dysregulated response to the infection as required to meet Sepsis 3 criteria. Therefore, the 
documentation does not support the diagnosis of sepsis with multiple chronic conditions and, therefore, the 
DRG 872 is more appropriate for this admission.  
 
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 rendered from March 12, 2019, to March 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venography, extremity, bilateral, radiological 
supervision and interpretation (75822), Venography, extremity, unilateral, radiological supervision and 
interpretation (75820), Ultrasound guidance for vascular access requiring ultrasound evaluation of potential 
access sites (76937), Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports (99152). 
 
You asked the Plan to pre-approve multiple venous procedures, intravascular ultrasound, and sedation. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 multiple venous procedures, 
intravascular ultrasound, and sedation. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
support the medical necessity of the treatments in question. There is no documentation of whole leg edema. 
There is no evidence of proximal venous obstructive findings on noninvasive imaging. As there are no 
complaints attributable to iliac venous obstruction and no documented physical examination or noninvasive 
findings suggestive of iliac venous obstruction, medical necessity has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple venous procedures, intravascular ultrasound, and sedation have not 
been met. Therefore, we decided that the Plan does not have to pre-approve venography, extremity, bilateral, 
radiological supervision and interpretation (75822), Venography, extremity, unilateral, radiological supervision 
and interpretation (75820), Ultrasound guidance for vascular access requiring ultrasound evaluation of potential 
access sites (76937), Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports (99152).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided November 28, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that PrismRA should be considered medically 
necessary for the enrollee. The Plan denied your request. The Plan says this request is not medically necessary 
because PrismRA has not been cleared or approved by the FDA.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. PrismRA has not been cleared or approved by the FDA. Online 
search of the FDA list of cleared or approved companion diagnostic testing does not mention this PrismRA. 
Search of the DEX Diagnostic Exchange registry for the diagnostic program MolDX Technical Assessment, 
states that this PrismRA test is not covered. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the PrismRA testing (81479) provided November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 3, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this claim was filed timely. 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 laboratory services was not filed until February 3, 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 laboratory services provided on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code 
L89.523 rendered from March 10, 2022, through March 14, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
requirements for coding and documentation were met. The Plan denied your request. The Plan says the DRG 
was updated. 
 
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 diagnosis code L89.523. 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 services at issue in this case were not supported by the medical records. Our physician 
reviewer found that there was no clinical evidence of a Stage III pressure ulcer in the medical record. The 
review has determined that the documentation did not support diagnosis code L89.523. The records support 
more DRG 603.  
 
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 billed with diagnosis code L89.523 rendered from March 10, 2022, through 
March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99211, 81045, and 99283 for date of service 
August 18, 2022. 
 
You asked the Plan to pay for procedure codes 99211, 81045, and 99283. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 99211, 81045, and 99283 is not supported in the medical record. Specifically, code 
99211 has a status indicator of B, which means this code is not recognized by OPPS when submitted on an 
outpatient hospital Part B bill type. This error has denied the entire claim. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99211, 81045, and 99283 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 99211, 81045, and 99283 for date 
of service August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 for date of service January 20, 2023. 
 
You asked the Plan to pay for procedure code 99203. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 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. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, this code is for a new 
patient. However, in the enrollee's claim history, the enrollee was seen by this provider within three years prior. This means this code is not supported. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99203 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99203 for date of service January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0482) presumptive drug testing 
(80307, 80305) provided December 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached medical records 
to support the services rendered. The Plan denied your request. The Plan says the explanation of benefits from 
the primary care provider is needed before payment will be considered. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, there is another payer 
indicated as the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the 
laboratory services until the primary insurer has denied the claim for these services.  Therefore, we decided that 
the Plan does not have to pay for the definitive drug testing (G0482) presumptive drug testing (80307, 80305) 
provided December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 27, 2022, to 
December 19, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted and these charges 
should be covered. 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 October 28, 2022. The NOA was not received by the Plan until January 16, 
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 27, 2022, to December 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 29, 2022, to August 
12, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed 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 May 30, 2022. The NOA was not received by the Plan until September 22, 
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 July 29, 2022, to August 12, 2022.