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

 
We decided that the Plan does not have to pay for the home health services provided December 20, 2022, to 
December 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 December 20, 2022. The NOA was not received by the Plan. 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 the home health services provided December 20, 
2022, to December 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Injectafer injection (J1439). 
 
You asked the Plan to pre-approve an Injectafer injection. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 an Injectafer injection have been met. 
Specifically, records were requested and never received.  Medical necessity cannot be established without this documentation. Therefore, we decided that the Plan does 
not have to pre-approve an Injectafer injection (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service June 29, 
2022. 
 You asked the Plan to pay for procedure code(s) 88305. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is included in the facility payment and 
is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service June 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the peer-reviewed literature supports 
the request for this procedure The Plan denied your request. The Plan says medical studies haven't proven this 
service/item is helpful for treatment of the enrollee's health problem.  
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no Magnetic Resonance Imaging (MRI) showing only modic changes 
without facet degenerative disc disease or foraminal stenosis. Thus, the requested service is 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Cxbladder Detect provided on November 14, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the Cxbladder Detect does not meet the Medicare guidelines for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that this testing is appropriate, and has been found to have high sensitivity, negative predictive value 
(NPV), specificity, positive predictive value (PPV) in comparison to other urine-based detection tests. The 
CxBladder Current Procedural Terminology (CPT) codes of 0012M along with 0013M are also included in 
CMS clinical laboratory fee schedule.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
the Cxbladder Detect provided on November 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve monitoring feature/device (A9279). 
 
You asked the Plan to pre-approve monitoring feature/device. You say that the items are necessary. The Plan 
denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for A9279 (MONITORING 
FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, 
COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED) are denied as statutorily non-
covered (No Medicare benefit). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of monitoring feature/device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve monitoring feature/device (A9279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667) 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you ask for 
review of the denial with the closed clinical documentation to support medical necessity for the prescribed 
Flexitouch pneumatic compression device with truncal and lower garments. The Plan denied your request. The 
Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed 
four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services represented with codes 81223, 81238, 
81241, 81242, 81249, 81250, 81279, 81298, 81307, 81317, 81321, 81339, 81320, 81404, 81406, 81408, 81400, 
and 81479 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services represented with codes 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 
81307, 81317, 81321, 81339, 81320, 81404, 81406, 81408, 81400, and 81479
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 99199 rendered on 
January 10, 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 this is not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for procedure 
codes 96365, 96366, and 99199 rendered on January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for March 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 20610. Payment for code J3490 is included in the global surgical payment for 20610. 
Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 for March 
21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 for date of service January 11, 2023, 
to January 12, 2023. 
 
You asked the Plan to pay for procedure code 99292. 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 the actual number of units 
provided for each procedure code. 
 
We find that 6 units of CPT code 99292 are not supported in the medical record. The medical record only 
supports 6 units of CPT code 99292. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99292 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99292 for date of service January 11, 2023, to January 12, 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 IRF care. You say that the enrollee will benefit from inpatient rehabilitation 
that cannot be accomplished in a lower level of care. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to an inpatient rehabilitation. 
 
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 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care services (99220) provided on 
December 31, 2022. 
 
You asked the Plan to pay for initial observation care services. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has two types of excludes notes. 
An Excludes1 note indicates that the code excluded should never be used at the same time as the code above 
the Excludes1 note. 
 
We looked at the file and Medicare rules. We noted that the initial observation care services at issue have been reported with diagnosis codes N18.5 and N18.6. Diagnosis code N18.5 has an Excludes1 note that indicates 
code N18.6 cannot be used at the same time as N18.5. Based on this information, we decided that Medicare 
rules for coverage of initial observation care services have been met. Therefore, we decided that the Plan does 
not have to pay for initial observation care services (99220) provided on December 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 21, 2022, 
to September 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not believe a NOA is 
required. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 21, 2022, to 
September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for date of service December 
19, 2022. 
 You asked the Plan to pay for procedure code 87506. You say that this service was billed correctly. The Plan 
denied your request. The Plan says payment for code 87506 is bundled into payment for code 87507. 
 
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 87506 
is a column II code to column I code 87507. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 87506 billed for date of service December 19, 
2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation of speech sound production with evaluation of language 
comprehension and expression (92523) provided on February 6, 2023. 
 
You asked the Plan to pay for the speech therapy services. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says that this service does not meet the coverage requirements in tile 
applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
The Plan follows Medicare rules. Medicare rules say that cognitive skills development describes interventions 
used to improve, maintain, or prevent further deterioration of cognitive skills, (e.g., attention, memory, problem 
solving) with direct (one-on-one) patient contact by the clinician. It may be medically necessary for patients 
with acquired cognitive impairments from head trauma, acute neurological events (including cerebrovascular 
accidents), or other neurological disease. 
 
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 speech therapy services. Our reviewer 
says that the speech therapy service is medically necessary. Our physician reviewer found the provided records 
indicate the enrollee was seen for treatment for impaired cognition and memory by a speech language 
pathologist in order to improve memory and executive function and to increase independence and 
participation in functional tasks. Therefore, the reviewer found that the speech therapy service was medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the speech therapy services have been met. Therefore, we decided that the Plan 
has to pay for the evaluation of speech sound production with evaluation of language comprehension and 
expression (92523) provided on February 6, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on February 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that this claim is payable and should be processed. The 
Plan denied your request. On its Remittance Advice, the Plan says that "this entity or provider cannot be 
located." 
 
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 has provided absolutely no explanation for its denial.  The 
only notation to why the Plan denied this claim is a short note at the bottom of the Remittance Advice.  The 
Plan has failed to provide any context or analysis of this denial rationale.  The Plan has failed to cite to any rule 
that would support its denial.  The burden is on the Plan to show why its denial is correct.  By failing to provide 
any of this information, we find that the Plan has not met this burden. Therefore, we decided that the Plan has 
to pay for lab services provided on February 1, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 16, 2022, 
to March 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required NOA 
on time. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 16, 2022, to 
March 17, 2022.