Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 19, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you should not have a copay for the second visit because the service is usually done within one visit. The Plan denied your request. The Plan says you were charged this copayment 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 $30 copayment for Vision Care. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the Vision Care benefit category. This means that 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 the office visit provided on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on December 15, 2020.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
October 26, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the service required authorization, which was not obtained prior to the 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 17, 2020.
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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 15, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time.
The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 30, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 a referral to an out-of-network dermatologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on February 21, 2020.
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 procedure code 99152 is 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 99152 is Moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of intra-service time for moderate sedation services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on February 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 2, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the service required authorization and the out of network provider would be responsible for securing a prior authorization.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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unclassified drug injections performed on July 21, 2020 and reported with HCPCS code J3490.
You asked the Plan to pay for the unclassified drug injections. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Drug codes should be reported with the applicable drug administration codes. In this case, the HCPCS Code Manual definition of code J3490 is unclassified drug injections. We find that HCPCS code J3490 is not supported in the medical record. Specifically, the injectable drug code was reported without an applicable drug administration code. Based on this information, we decided that Medicare rules for coverage of the unclassified drug injections have not been met. Therefore, we decided that the Plan does not have to pay for the unclassified drug injections performed on July 21, 2020 and reported with HCPCS code J3490.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 24, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time.
The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 4, 2020.
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 the testing is not covered.
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, a cardiovascular risk assessment panel, 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 rendered on November 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 16, 2020.

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 procedure code 99284 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 99284 and 99285. Code 99284 is a column II code with a modifier indicator of 1 when billed with column I code 99285. Code 99284 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on January 4, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are not covered.
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 G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that a presumptive test was inconsistent with the enrollee's medication plan or self-report. The enrollee's historical use, medication response, and clinical assessment do not show that testing of 22 or more drugs was indicated. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided on January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0482) provided on May 27, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of the testing.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the documentation submitted does not include a physician order or clear intent to order the billed laboratory services. There is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for drug testing services (G0482) provided on May 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for selective catheter placement (36215) and angiography, extremity, unilateral (75710) provided October 20, 2020.

You asked the Plan to pay for selective catheter placement and angiography, extremity, unilateral. You say that these procedures are documented in the medical records. The Plan denied your request. The Plan says the billed codes are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our Coder 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 selective catheter placement and angiography, extremity, unilateral. Our reviewer says that the codes at issue are not supported by the medical records. Our Coder reviewer found the medical records provided do not include sufficient documentation to validate a separately reportable selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family (36215), therefore this procedure cannot be verified. The medical records provided do not include sufficient documentation to support the billing of 75710 on October 20, 2020, therefore this service cannot be verified.

We looked at this Coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of selective catheter placement and angiography, extremity, unilateral have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement (36215) and angiography, extremity, unilateral (75710) provided October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 25, 2020, to December 21, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 pay for lab work provided on November 25, 2020, to December 21, 2020 by an out of network (OON) provider.