Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered from September 16, 2019 to September 19, 2019.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 97112 and 97530 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 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.We find that CPT codes 97112 and 97530 are not supported in the medical record. Specifically, the documentation does not support that 38 through 52 minutes of therapy services were spent on the enrollee to support code 97112 and 97530. 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 forthe physical therapy services rendered from September 16, 2019 to September 19, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on July 12, 2019.You asked the Plan to pay forthese 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 physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not contain evidence of the presence of an independent trained observer to assist with monitoring the enrollee's level of consciousness and physiological status. 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 forthe moderate sedation services rendered on July 12, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the admission criteria for an LTACH. The Plan denied your request. The Plan says ongoing care for skilled needs can be met in a lower level of care. The plan says that the enrollee is unable to ween from a ventilator and ongoing care for chronic ventilator training can occur in a lower level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted and managed for diverticulitis with abscess. The enrollee subsequently went into septic shock and respiratory failure and was placed on a ventilator. The enrollee underwent an exploratory lap with subtotal colectomy and drainage of a pelvic abscess. The enrollee has undergone 3 weaning attempts. There is no documentation provided necessitating admission to an LTACH. It appears the enrollee can adequately receive the care needed for ongoing ventilator weaning in the current location. The enrollee requires respiratory support, monitoring, and management of lungs, fluid management, wound care, and possible additional surgical management, monitoring of kidneys, IV antibiotics, nutritional support, management of blood pressure, frequent labs, and doctors' visits and physical therapy which can be safely done in the current acute care setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe neuromuscular junction testing coded 95937, short-latency somatosensory evoked potential study coded 95938, and the electroencephalogram coded 95955 provided on June 14, 2019.You asked the Plan to pay forthe neuromuscular junction testing, short-latency somatosensory evoked potential study, and the electroencephalogram. 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 medically necessary.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 pay for the neuromuscular junction testing, short-latency somatosensory evoked potential study, and the electroencephalogram. Our reviewer says that the documentation does not support that the testing provided was medically reasonable or necessary. Our physician reviewer found the enrollee has routinelumbar surgery below the level of the spinal cord. There is no clinical need for intraoperative neurophysiologic monitoring. The documentation does not support that the intraoperative neurophysiologic monitoring provided was standard of care.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 neuromuscular junction testing, short-latency somatosensory evoked potential study, and the electroencephalogram have notbeen met.Therefore, we decided that the Plan does not have to pay forthe neuromuscular junction testing coded 95937, short-latency somatosensory evoked potential study coded 95938, and the electroencephalogram coded 95955 provided on June 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous process spacer (22869).You asked the Plan to pre-approvethe insertion of an interspinous process spacer. You say that this is a medically necessary procedure.The Plan denied your request. The Plan says a  lumbar interspinous spacer is not a standard treatment for spinal stenosis. There is not enough medical proof that shows the safety or success of lumbar interspinous spacers when used for this reason.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-approvethe insertion of aninterspinous process spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer remains experimental. More research is needed before it can be considered medically necessary under Medicare rules.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe insertion of aninterspinous process spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of an interspinous process spacer (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92012) provided on July 18, 2019.You asked the Plan to pay for the eye exam. You say that the member was seen by two different providers on the same day for separate issues. The Plan denied your request. The Plan says the billed service was reported with an inappropriate modifier.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 92012 is not supported in the record. Specifically, modifier 77 should not be billed with evaluation and management codes. Based on this information, we decided that Medicare rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92012) provided on July 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Facet Joint Injections (64495, 206834, 64494, 64493) to be provided.You asked the Plan to pre-approvethe facet joint injections. You say that the injections are medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the facet joint injections. Our reviewer says that the requested injections are not medically necessary at this time. Our physician reviewer found Facet Joint Injections are only covered when non-facet pathology has been ruled out. In this case there are multiple other probable pain generators, including multi-level degenerative disc disease.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approveFacet Joint Injections (64495, 206834, 64494, 64493) to be provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy visit provided on October 2, 2019.You asked the Plan to waive the copayment forthe physical therapy visit. You say that you should not be responsible for the copayment because the provider did not inform you of the $40 copayment. The Plan denied your request. The Plan says 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 $40 copayment for each physical, occupational, and/or speech/language therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" category. This means that you have been asked to paythe 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 forthe physical therapy visit provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on September 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 96368 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 96368 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure).We find that CPT code 96368 is not supported in the medical record. Specifically, the documentation does not indicate that intravenous infusion was performed. 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 forthe services rendered on September 16, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroplasty.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has shoulder pain. The records do not show that she has had an adequate trial of conservative measures for shoulder pain. There must be a documented recent and adequate trial of physical therapy. The records do not support that the shoulder arthroplasty is reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvea shoulder arthroplasty.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 17, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on August 28, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0481 provided on September 16, 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 G0481 is 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; 8-14 drug class(es), including metabolite(s) if performed.We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests wereto 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 forthe drug testing coded G0481 provided on September 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.You asked the Planto pre-approve the injections. You say that this is medically necessary.The Plan denied your request. The Plan says the requested service is supported when the treatment plan shows that the region to be treated is no more than two levels of the spine on the same day.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 injections are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no radicular pain, which is an exclusion for these injections. Additionally, the LCD limits the number of injections to 4 (2 levels bilaterally). Therefore, the requested procedure is deemed not medically reasonable or necessary.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forPartial Hospitalization Mental Health Services provided August 5 to August 16, 2019.You asked the Plan to pay forthe mental health services. You say that services were medically necessary and correctly billed.The Plan denied your request. The Plan says the code billed is not valid for Medicare 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.We find that CPT code H0035 is not supported in the medical record. Specifically, code H0035 is marked with an "I" in the 2019 National Physician Fee Schedule. This denotes that the code is invalid for Medicare reimbursement. Based on this information, we decided that Medicare rules for coverage of the mental health services have not been met.Therefore, we decided that the Plan does not have to pay forPartial Hospitalization Mental Health Services provided August 5 to August 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve an epidural steroid injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plansaysthere is no documentation of neck pain.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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request for the cervical epidural is denied as the enrollee has no documentation of neck pain. There is no documentation of any abnormal neurological findings, or previous imaging of the neck or upper back. The review has determined that the enrollee does not meet the criteria for this request.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean epidural steroid injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99213) provided on October 2, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you are appealing the denied claim and feelthe notes will support the need for services.The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The referring provider listed is a non-participating provider. The plan did not authorize any services for a doctor who is a non-participating provider. The services are not considered urgent/emergent in nature. There is no referring provider listed. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. Services rendered by non-participating providers, require prior authorization as outlined in the enrollee's EOC.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 foran office visit (99213) provided on October 2, 2019 by out of network provider.