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

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 10, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for gait training (97116), therapeutic activities (97530) and wheelchair management (97542) provided on January 4, 2020 through January 29, 2020.
You asked the Plan to pay for the gait training, therapeutic exercises and wheelchair management. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing). The CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The CPT code Manual definition of code 97542 is wheelchair management (eg, assessment, fitting, training), each 15 minutes. 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 gait training, therapeutic exercises and wheelchair management. Our reviewer says that CPT codes 97116, 97530 and 97542do not meet criteria for billing or reimbursement consideration. Our reviewer found these codes are distinct procedural services and the documentation also does not indicate the time for each procedure to verify the number of units billed. 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 gait training, therapeutic exercises and wheelchair management have not been met. Therefore, we decided that the Plan does not have to pay for gait training (97116), therapeutic activities (97530) and wheelchair management (97542) provided on January 4, 2020 through January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 26,
2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 9, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this is an administrative determination for coding and is not based on clinical criteria. The Plan says that claims for this testing requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. Medicare billing criteria were not met.
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 claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 5, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on February 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) on March 30, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to pay for care you believe to be substandard. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $90 copayment for an emergency room visit. You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit (99283) on March 30, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 18, 2020 to February 16, 2020.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says this was custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found the submitted medical records do not show that the enrollee needed skilled nursing or therapy services. The beneficiary did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 18, 2020 to February 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 4, 2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says The Plan says this is an administrative determination for coding and is not based on clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (67966 eyelid repair) provided to the
enrollee on September 4, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the medical records provided do not support the services billed under code 67966.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and when necessary provide medical records to
support the services billed. In this case, the records provided are insufficient and do not support the services
billed. Based on this information, we decided that Medicare rules for coverage of this service have not been
met. Therefore, we decided that the Plan does not have to pay for surgical services (67966 eyelid repair)
provided to the enrollee on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided on September 6, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid as billed. The Plan denied your request. The Plan says documentation submitted indicates that assistant surgical services were performed by a Surgical Technologist/Surgical First Assistant (CST/CSFA). The Plan says that skilled, certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines. The Plan also states the submitted operative note did not mention any name of the assistant surgeon. Finally, the Plan states that per CMS/Medicare guidelines, the services of Surgical Technicians and RN First Assists (RNFA) are not eligible for separate reimbursement. Reimbursement for those services is included in the global claim to the facility. The Plan notes that multiple attempts were made to contact the provider for additional information.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the records provided do not support the services billed. Therefore, we decided that the Plan does not have to pay for surgery services provided to the enrollee on September 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on March 27, 2020
and billed under code 73551.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says this claim was denied because this service was included in CPT code 73552
(Radiologic examination, femur; minimum 2 views) that was billed a previous claim by the same provider.
The Plan says code 73551 is a column II code to the more comprehensive column 1 code 73552. The Plan
states that a modifier can differentiate between the services provided, however, a modifier was not appended.
In addition, the documentation submitted did not include medical records supporting that CPT code 73551 was
performed or that it was distinct from CPT code 73552. Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and when necessary report the correct modifier.
In this case, the claim submitted cannot be paid as billed due to the absence of a modifier to differentiate the
service from a previously submitted claim. Therefore, we decided that the Plan does not have to pay for
medical services provided to the enrollee on March 27, 2020 and billed under code 73551.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for preventative vaccines or immunizations provided before
travel on February 26, 2020.
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that these vaccines should
be covered by the Plan. The Plan denied your request. The Plan says your provider has been counseled to
submit these for reimbursement under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative
vaccines under Medicare Part B. The Plan follows the same rules. The records do not show that you have been
injured or directly exposed to any illness related to preventative vaccines under Medicare Part B. Therefore, we
decided that the Plan does not have to pay for preventative vaccines or immunizations provided before travel
on February 26, 2020.
Benefits for preventative vaccines under Medicare Part B may be available under Medicare Part D. Contact the
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compounded drug provided on August 21, 2019.
You asked the Plan to pay for the compounded drug (J7999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says a modifier to indicate this is a compounded drug was not submitted therefore the billed service and units cannot be verified.
The Plan must follow Medicare rules. The rules state that when billing for compounded drugs report HCPCS code J7999 with the KD modifier on a single claim line. The claim was not billed with the KD modifier. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the compounded drug provided on August 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided to the enrollee on May 5, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was denied because it was reported with a diagnosis (Z87.891: Personal history of nicotine dependence) which does not support the procedure based on a medical journal. The Plan sates current guidelines state "In patients at risk for developing lung cancer, screening for lung cancer with [chest x-ray] once or at regular intervals is not recommended". Therefore, the appeal for CPT code 71045-26 (Chest X ray; 1 view) will be upheld. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, was requested for screening purposes. Medicare does not cover this imaging for screening purposes. Therefore, we decided that the Plan does not have to pay for x-ray services provided to the enrollee on May 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020 to February 4, 2020 and from February 7, 2020 to February 22, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020 to February 4, 2020 and from February 7, 2020 to February 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided to the enrollee on February 21, 2020.
You asked the Plan to pay for the services. You say that these services do not require authorization. The Plan denied your request. The Plan says authorization is absent.
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 has network providers available who can provide 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 pay for x-ray services provided to the enrollee on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 25,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 units of saline solution (J7050) provided on October 11,
2019.
You asked the Plan to pay for saline solution. You say that this code is supported. The Plan denied your
request. The Plan says this was fluid used to administer the drug and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We asked our 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 saline solution. Our reviewer says that the
use of this code is not supported. Our physician reviewer found the records show that this code was used for the
fluid used to administer the drug and is not separately payable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of saline solution have not been met. Therefore, we decided that the Plan does not
have to pay for 2 units of saline solution (J7050) provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We are dismissing your case. The Plan agreed to pay for the office visit. Therefore, there is no need for a coverage decision.