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

We decided that the Plan does not have to pay for the surgical services rendered on September 14, 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 codes 51784 and 51741 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code is 51741 is complex uroflowmetry (eg, calibrated electronic equipment). The definition of code 51784 is electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique.

We find that CPT codes 51784 and 51741 are not supported in the medical record. Specifically, there is no documentation of complex uroflowmetry to support code 51741.

There is no documentation of EMG of anal or urethral sphincter to support code 51784. 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 surgical services rendered on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional sedation services (99153) provided on October 8,
2020.

You asked the Plan to pay for additional sedation services. You say that this is supported in the records. The
Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to
suppliers of the technical component (TC) of a radiology service for beneficiaries in a hospital inpatient stay. In
the Physician Fee Schedule, a Professional Component (PC)/Technical Component (TC) Indicator of 3
indicates technical component only codes.

We looked at the file and Medicare rules. Code 99153 has a PC/TC indicator of 3, meaning it is a technical component
only code. The record shows that the enrollee was an inpatient at the time of service, meaning
technical components cannot be paid. Based on this information, we decided that Medicare rules for coverage
of additional sedation services have not been met. Therefore, we decided that the Plan does not have to pay for
additional sedation services (99153) provided on October 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code
81479), for the enrollee.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the testing have not been met. Medicare denies coverage for all
cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with
suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for
cardiovascular risk assessment testing / panels (CPT code 81479), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from June 16, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 pre-approve continuation of SNF care from June 16, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction vision services (92015) provided February 23, 2021.

You asked the Plan to pay for the vision services. You say that you received your annual eye exam with a Plan
provider. As part of the exam, you received refraction treatment. You hope the Plan will reexamine your
coverage for this particular service and provide you with a refund. The Plan denied your request. The Plan says
refractions are only covered if they are routine and performed by a routine vision care provider.

Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine
vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when rendered by a routine vision care provider found in the routine
vision care section of the Plan's provider directory.

We looked at the file and the Plan's rules. Refractive services are not covered under benefit plan unless
rendered by a routine vision care provider found in the routine vision care section of the Plan's provider
directory. Based on this information, we decided that the Plan's rules for coverage of the vision services have
not been met. Therefore, we decided that the Plan does not have to pay for refraction vision services (92015)
provided February 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
December 20, 2020, through December 21, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services is 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was enrolled into Hospice. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a moderate assist level for functional mobility including gait to 25 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee tolerated a pureed diet and honey thickened liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from December 20, 2020, through
December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm (CPT code 81455) provided to the enrollee on December 15, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. The rules say that targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5-50 genes (EG, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed is considered not medically necessary except when used to guide treatment decision making in individuals with non-small cell lung cancer. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm (CPT code 81455) provided to the enrollee on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no medical indication to support the need for a battery-operated unit.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.

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 concentrator. Our reviewer says that
the concentrator at issue in this case is not medically reasonable or necessary. Our physician reviewer found the
medical records do not contain any documentation that support the need for this request. There is no indication
that you are unable to use a portable tank system for mobility within the home. You have been offered home
oxygen, including a portable system, but have refused.

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 concentrator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).

You asked the Plan to pre-approve the orthosis. You say that given that traditional rehab strategies had been tried and failed, the enrolle's primary care nurse practitioner referred him for myoelectric orthotic restoration.The Plan denied your request. The Plan says this device is considered experimental and investigational as medical studies have not proven that the device is helpful for the 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. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided to the enrollee on August 14, 2020.

You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your request. The Plan says this is a duplicate charged and the provider has already confirmed they received payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Review of the records show that this a duplicate claim and the provider has already confirmed they received payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided to the enrollee on August 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on May 18, 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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these 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 physical therapy services rendered on May 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on May 29, 2020.You asked the Plan to pay for code 97110. 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 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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.We find that CPT code 97110 is not supported in the medical record. Specifically, the submitted documentation did not include medical records for the billed date of service. Based on this information, we decided that Medicare rules for coverage of code 97110 have not been met.Therefore, we decided that the Plan does not have to pay fort he therapy services represented by code 97110 provided on May 29, 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 August 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 definitionof 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 orintramuscular. 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 theSanexas 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 August 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean NGS panel for ALS/FTD/Parkinson's.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is considered experimental and investigational.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of testing for this clinical situation is not supported by current literature. Identifying a genetic pattern does not diagnose ALS or other conditions and has not been shown to improve overall outcomes compared to standard testing and treatment. Therefore, this request for genetic testing does not meet criteria.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 not been met.Therefore, we decided that the Plan does not have to pre-approve an NGS panel for ALS/FTD/Parkinson's.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a brace provided by a participating provider on January 7, 2021.You asked the Plan to waive the coinsurance for durable medical equipment. You say that the brace was off the shelf. You say that these charges need to be reduced.The Plan denied your request. The Plan says the correct coinsurance has been applied.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 20% coinsurance for durable medical equipment/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $286.29. The total amount you are being asked to pay is $57.26 ($286.29 x 20% = $57.26). The correct coinsurance has been applied to the brace that was provided. Durable medical equipment falls within the durable medical equipment/in-network 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 coinsurance for a brace provided by a participating provider on January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) thorax (71250) provided on October 22, 2020 by an out of network (OON) provider.You asked the Plan to pay for the CT scan. You say that you have attached medical records to show that service was medically necessary at the time of service. Please review and reprocess the claim for payment.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for computed tomography (CT) thorax (71250) provided on October 22, 2020 by an out of network (OON) provider.