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

We decided that the Plan does not have to pay for the surgical services provided on December 2, 2020, billed with codes 25078-51-79 and 64722-59-79.
You asked the Plan to pay for the surgical services as billed. You say that these services were billed correctly. The Plan denied your request. The Plan says the codes at issue were not supported in the record.
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 25078 is Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; 3 cm or greater. The definition of 64722 is Decompression; unspecified nerve(s) (specify). We asked our coding 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 surgical services as billed. Our reviewer says that the documentation does not support these two billed codes. Our coding reviewer found per operative report, "the procedure commenced with wide excision of the right proximal dorsal forearm invasive squamous cell carcinoma, keratoacanthoma type with minimal 10 mm margins excising in tear-drop-shaped fashion with the apex proximal and radial and drawn at as much of an obtuse angle as would be permitted with respect to the previous excision and reconstruction". Operative report supports excision of squamous cell carcinoma, there is a more appropriate code to report for this procedure. Therefore, CPT 25078 would not be covered. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. The documentation does not support the use of modifier -59 with code 64722. 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 surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on December 2, 2020, billed with codes 25078-51-79 and 64722-59-79.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder surgery services provided on December 18, 2020, billed with code 29823.
You asked the Plan to pay for the surgical services as billed. You say that the services should be paid due to medical necessity. The Plan denied your request. The Plan says the code 29823 is not documented in the record.
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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). We asked our coding 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 surgical services as billed. Our reviewer says that the billed services are not supported by the records provided. Our reviewer found the medical records provided do not include sufficient documentation to verify that extensive debridement was performed in multiple areas where no other work was performed. Extensive debridement is defined as, "debridement in the anterior and posterior compartments, or chondroplasty/bone debridement, or soft tissues in multiple areas where no other work was performed". This description was not included in the operative note. 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 surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder surgery services provided on December 18, 2020, billed with code 29823.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs/vitamins provided in the nutria-pharmaceutical injection on September 3, 2020 billed with multiple units of code J3490.
You asked the Plan to pay for the drug/vitamin injection. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says these drugs were not correctly billed.
The Plan must follow Medicare rules. Medicare rules say that compounded drugs must be reported using the NOC compounded drug code. In this case, multiple agents are compounded into a single pre-filled syringe. This should be reported as J7999, compounded drug NOC. Therefore, we decided that the Plan does not have to pay for the drugs/vitamins provided in the nutria-pharmaceutical injection on September 3, 2020 billed with multiple units of code J3490.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, disposable underpads (A4554).
You asked the Plan to pre-approve incontinence supplies. You say that you have a diagnosis of colon cancer
and will need incontinence supplies. The Plan denied your request. The Plan says this item is not covered.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, disposable
underpads (A4554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99291) provided January 26, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation 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 99291 is a critical care visit of 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 30-74 minutes was spent on this service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99291) provided January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 15, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 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 tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home physician visit (99347) provided September 23, 2019.
You asked the Plan to pay for the home physician visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation 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. We find that CPT code 99347 is not supported in the medical record. Specifically, the records do not show that the physician was present in the enrollee's home during the visit. Based on this information, we decided that Medicare rules for coverage of the home physician visit have not been met. Therefore, we decided that the Plan does not have to pay for a home physician visit (99347) provided September 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99397) provided on August 19, 2019.
You asked the Plan to pay for the home visit. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home.
Although the note appears to be signed by a physician, only the RN was actually present in the enrollee's home. Therefore, we decided that the Plan does not have to pay for the home visit (99397) provided on August 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 12, 2020, described by codes 44500 and 30999.
You asked the Plan to pay for the medical services. You say that this should be paid. The Plan denied your request. The Plan says the services are not supported and would be included in the inpatient hospital payment.
The Plan must follow Medicare rules. Medicare rules say that provider must submit documentation to confirm that Medicare coverage criteria are met.
No clinical documentation was submitted for review. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 12, 2020, described by codes 44500 and 30999.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on November 19, 2020, billed with codes 80299-59, 82542-59, and 83789-59.
You asked the Plan to pay for the billed testing services. You say that this should be paid in full. The Plan denied your request. The Plan says the additional codes are inclusive to the paid services.
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 coding 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 billed testing services. Our reviewer says that the documentation does not support separate payment for these codes. Our coding reviewer found providers should report services the highest specificity as documentation allows, and without unbundling procedures. CPT 80299, CPT 82542 and CPT 83799 are inclusive to Healthcare Common Procedure Coding System (HCPCS) G0480, which was paid on this claim. Separate payment for these inclusive services is not allowed. 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 billed testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on November 19, 2020, billed with codes 80299-59, 82542-59, and 83789-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns, pontic, core buildup, and medications.
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 not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns, pontic, core buildup, and medications.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee requires skilled therapy services in the SNF setting. The Plan denied your request. The Plan says they have no contractual obligation to cover services that are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is mobilizing and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation therapy provided on February 8, 2021.
You asked the Plan to waive the copayment for the radiation therapy. You say that you had laboratory work before getting admitted and you believed this was covered. The Plan denied your request. The Plan says the claim has been reprocessed and you have been charged the correct cost sharing amount.
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 $60 copayment per visit for sleep studies and nuclear medicine or radiation therapy, including but not limited to cancer treatment. You have been asked to pay a $60 copayment for the radiation therapy. The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 radiation therapy provided on February 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from July 20, 2020 to July 24, 2020.
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from July 20, 2020 to July 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on May 14, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an x-ray on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $35 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an x-ray on May 14, 2021. You have been asked to pay a $35 copayment for the x-ray. The x-ray falls within the Outpatient diagnostic tests 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 x-ray provided on May 14, 2021.
Your complaint about feeling you should not be responsible due to the technician's error is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support this device as safe and effective as the gold standard of surgical decompression.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pre-approve the Myopro device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records provided do not cite failure of specific modalities and/or devices.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the Myopro device at issue in this case meets Medicare criteria for medical necessity. The available medical records from the enrollee's treating provider does not document necessity of the device and current guidelines consider robotic therapy of "uncertain utility compared with dose-matched conventional upper limb exercise therapies." We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Myopro device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided by a PT assistant (PTA) in the home setting on July 13, 2020.
You asked the Plan to pay for the PTA services. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says this physician was not physically present during the PT services.
The Plan must follow Medicare rules. Medicare rules say that PTA services cannot be billed incident to a physician service because the PTA must be under the supervision of a therapist. In addition, the physician must be directly supervising any service billed incident to their professional services. In this case, the supervising provider was not a therapist as required for PTA services, and this provider was not physically present in the home. As such, these services cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided by a PT assistant (PTA) in the home setting on July 13, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve below knee gradient compression wraps (A6545).
You asked the Plan to pre-approve the wraps. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate chronic venous ulceration.
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 wraps. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the submitted documentation does not indicate that the member has chronic venous ulcerations. The enrollee has venous stasis dermatitis. The enrollee does not meet the criteria for the requested below knee gradient compression wraps (A6545). 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 wraps have not been met. Therefore, we decided that the Plan does not have to pre-approve below knee gradient compression wraps (A6545).