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

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 21, 2020.

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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed.

We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 G0482 provided on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 15, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 60252 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 60252 is thyroidectomy, total or subtotal for malignancy; with limited neck dissection.

We find that CPT code 60252 is not supported in the medical record. Specifically, the operative report does not contain documentation of a total or subtotal thyroidectomy for malignancy with limited neck dissection. 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 December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from November 24, 2020, through December 23, 2020.

You asked the Plan to pay for the continuation of SNF services. The Plan denied your request. The Plan says there are no daily skilled nurse or therapist needs.

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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. As a practical matter, the enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from November 24, 2020, through December 23, 2020. 

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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation SNF services provided from November 24, 2020, through December 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an EGD provided on February 5, 2021.

You asked the Plan to waive the co-payment for an EGD. You say that you were told that you would only owe a $350 co-payment. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 co-payment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $350 co-payment for an EGD. An EGD 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 co-payment for an EGD provided on February 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on September 5, 2020.

You asked the Plan to pay for the therapeutic procedure 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 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 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 documentation supports that the services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code to be billed for these services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor accessories provided on January 7, 2021.

You asked the Plan to pay for the glucose monitor accessories. 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. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that there is no evidence of an established relationship between the enrollee and the ordering physician. In addition, the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the glucose monitor accessories provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 the physician services provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on August 31, 2020 by an out of
network provider.

You asked the Plan to pay for psychotherapy (90837). You say that there was no adequate time frame to
request authorization. The Plan denied your request. The Plan says you did not request prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 psychotherapy provided on August 31, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99121) provided January 6, 2021.

You asked the Plan to pay for the office visit. You say that you are also including a document you received with approval of 11 chiropractic services between January 6, 2021 and March 6, 2021. Please review this concern. The Plan denied your request. The Plan says this service is not covered when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99121) provided January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foam dressing, wound cover, sterile (A6209) gauze, non-impregnated, non-sterile (A6216) specialty absorptive dressing, wound cover, sterile (A6252) conforming bandage, non-elastic, knitted/woven, sterile (A6446) provided on January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the wound supplies. You say that please review the documentation and reconsider these services for reimbursement. Doctor order shows medical necessity and online eligibility shows no mention of authorization or referral required. 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 foam dressing, wound cover, sterile (A6209) gauze, non-impregnated, non-sterile (A6216) specialty absorptive dressing, wound cover, sterile (A6252) conforming bandage, non-elastic, knitted/woven, sterile (A6446) provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Zilretta (J3304) provided on December 29, 2020.

You asked the Plan to waive the coinsurance for Zilretta. You say that you have already paid for the medication at issue. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for Medicare Part B prescription drugs. 

The Plan has attested that the price you paid previously was for a separate treatment with a different drug on the same date of service. You have therefore been asked to pay $116.50, or 20% of the Medicare-allowed amount of $582.53, for Zilretta. Zilretta falls within the "Medicare Part B prescription drugs" 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 treatment with Zilretta (J3304) provided on December 29, 2020.
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 experimental and investigational procedures are not covered by Medicare.

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 procedure 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) received January 4, 2021.

You asked the Plan to pay for the resin-based composite. You say that the Plan should pay 50% of the cost for the procedure. The Plan denied your request. The Plan says the requested procedure has a frequency limitation.

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. The Plan covers the resin-based composite when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. The Plan contract states that restorative dental services are eligible for coverage, however frequency limits apply. The requested service is limited to one procedure per tooth every 12 months. The Plan has submitted evidence that this procedure was last covered by the Plan for this tooth on July 1, 2020; therefore this benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay for the resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) received January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management provided on June 11,
2020.

You asked the Plan to pay for hospital discharge day management; more than 30 minutes (99239). You say that
the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted does
not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more.

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 99239 is Hospital discharge day management; more than 30 minutes. 

We find that CPT code 99239 is not supported in the medical record. Specifically, there is no recorded duration of time of the service. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management; more than 30 minutes (99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Continuous Positive Airway Pressure (CPAP) supplies for continued use of CPAP.

You asked the Plan to pre-approve CPAP supplies. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because there was no CPAP compliance report submitted to show that the enrollee had adhered to CPAP therapy.

The Plan follows Medicare rules. Medicare rules state that continued coverage of a positive airway pressure device (and therefore the associated supplies) requires a clinical re-evaluation that documents the enrollee is benefiting from PAP therapy.

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 CPAP supplies. Our reviewer says that the enrollee does not meet the Medicare criteria for continued use of CPAP. Our physician reviewer found the enrollee has obstructive sleep apnea and is on CPAP at night. The record does not indicate how long the enrollee has been on CPAP. There is no documentation from a device download that the enrollee is using the device enough to meet minimum Medicare requirements of at least 4 hours per day for at least 70% of days. Without that documentation, the supplies are not considered medically 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 CPAP supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Continuous Positive Airway Pressure (CPAP) supplies for continued use of CPAP.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan
denied your request. The Plan says the requested surgery 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 Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that this 61-year-old female was being treated for spinal stenosis, lumbar region, with
neurogenic claudication. She noted low back pain that radiates down into leg with the left being worse.
Bending or leaning forward relieves the pain. Long standing increases the pain. Current evidence based
medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure
over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed
outcome studies to support the use of this device for this enrollee's medical condition as discussed above.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and panoramic xray
provided on July 21, 2020, by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and panoramic x-ray. You say that you
confirmed with the Plan that the treating provider was in-network. The Plan denied your request. The Plan says
you do not have dental coverage for when services are rendered by an OON provider.

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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the periodic oral evaluation, prophylaxis, and panoramic x-ray provided on July 21, 2020, by an OON
provider.