Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services (99211, 90632) provided on November 5, 2018 to November 12, 2019.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says there were network providers available. Services were not emergent or preauthorized.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 forthe outpatient mental health services (99211, 90632) provided on November 5, 2018 to November 12, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the external electrocardiographic recording services provided on December 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for the external electrocardiographic recording services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 the external electrocardiographic recording services provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit services provided on August 28, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. 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 99350 is home visit for the evaluation and management of an established patient. We find that CPT code 99350 is not supported in the medical record. The documentation indicates that a clinician was not present at the time of the visit. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. 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 forthe home visit services provided on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0480) provided to the enrollee on October 23, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS,RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service HCPCS G0480:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS(any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted was reviewed. CPT 80307 and HCPC G0480 are not supported by documentation reviewed. There is no signed physician order indicating what tests are included in 8129-PremierTox 12 auto-Reflex Panel includes.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 services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0480) provided to the enrollee on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor sensors.You asked the Plan to pre-approve continuous glucose monitor sensors. You say that your CGM has helped you greatly in maintaining healthy blood sugar levels.The Plan denied your request. The Plan says you are not insulin treated so you do not meet the Medicare coverage criteria for a CGM or supplies.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.A CGM and supplies are not covered by Medicare when an enrollee is not on insulin.Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor sensors have not been met.Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor sensors.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 4, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat. You asked the Plan to pre-approve a raised toilet seat. You say that you have a hard time getting up off of the toilet and a raised toilet seat would make it easier for you to get up. You say that it is not a matter of hygiene but rather the requested raised toiled seat is a medical device for the handicapped. You asked the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9338 provided from January 30, 2020 to February 13, 2020.You asked the Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not 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.In this case, the CPT Code Manual definition of code S9338 is home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9338 is not supported in the medical record. Specifically, code S9338 has a status codeof "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9338 provided from January 30, 2020 to February 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of a trial of any conservative measures.
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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no indication that you have tried any conservative measures such as physical therapy, oral medications, bracing, or activity modification for 3 months. In addition there is evidence of radiculopathy. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial observation care, per day (99219) provided on June 30, 2018.You asked the Plan to pay forthis service. You say that you submitted your claim untimely as you did not receive proper notice of the member's benefit determination.The Plan denied your request. The Plan says the claim was submitted untimely, more than 365 days from when the service was rendered.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for this service was not filed until February 5, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe initial observation care, per day (99219) provided on June 30, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a bricker operation (50820), cystectomy (51570) and laparoscopy (38571) provided on January 15, 2020.
You asked the Plan to pay for the surgery. 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. 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 surgery. Our reviewer says that CPT code 50820 does not meet criteria for billing or reimbursement consideration. The medical records do not include documentation of a Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation) being performed on January 15, 2020, therefore this service cannot be validated. The medical records submitted indicate in the operative report that a radical cysto-prostatectomy with ileal conduit and pelvic lymph node dissection was performed Our reviewer found CPT code 51570 does not meet criteria for billing or reimbursement consideration. The medical records do not include documentation of a Cystectomy, complete; (separate procedure) being performed on January 15, 2020, therefore this service cannot be verified. CPT code 38571 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of a Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy being performed on Januray 15, 2020, therefore this service cannot be verified. The medical records submitted indicate in the operative report that a radical cysto-prostatectomy with ileal conduit and pelvic lymph node dissection was performed.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pay for a bricker operation (50820), cystectomy (51570) and laparoscopy (38571) provided on January 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of network (OON) agency.You asked the Plan to pre-approve the OON home health services. You say that you have not been able to find a network provider able to provide the level of services required by the enrollee. You feel that this means that the care must be covered by the Plan.The Plan denied your request. The Plan says there are network providers able to provide these services and the Plan is not required to approve these services from an OON provider.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services.Therefore, we decided that the Plan does not have to pre-approve home health services to be provided by an out of network (OON) agency.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast with computer-aided detection (77049).
You asked the Plan to pre-approve an MRI of the breast with computer-aided detection. You say that the service is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the breast with computer-aided detection. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not show any evidence of annual mammography to suggest extremely dense tissue or other factors which limit the utility of mammography of the remaining left breast. There is no history of a genetic abnormality that predisposes to breast cancer such as BRCA1/2 mutation. Absent other factors not included in the records the enrollee does not qualify for a medically necessary annual breast MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the breast with computer-aided detection have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast with computer-aided detection (77049).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair seat cushion.You asked the Plan to pre-approve the seat cushion. You say that the cushion is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.The Plan follows Medicare rules. Medicare rules say that the enrollee must have a history of a pressure ulcer or impaired sensation in the area that touches the seat surface.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 seat cushion. Our reviewer says that the seat cushion is not medically necessary. Our physician reviewer found there is no documentation in the records to show a current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface, or absent or impaired sensation in the area of contact with the seating surface, or inability to carry out a functional weight shift.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 seat cushion have not been met.Therefore, we decided that the Plan does not have to pre-approve a wheelchair seat cushion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a skin growth provided on January 2, 2020.You asked the Plan to waive the copayment for the removal of a skin growth. You say that you disagree with the outpatient surgical charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $270 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $189.62, which is less than the $270 copayment for the removal of a skin growth. The removal of a skin growth falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 removal of a skin growth provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided on December 11,
2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 80307 is drug test(s), presumptive, any number of drug
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD,
MALDI, TOF) includes sample validation when performed, per date of service.
We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation submitted
did not include a valid physician order/lab requisition form or medical records signed by the ordering physician
stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for
the drug testing coded 80307 provided on December 11, 2019.