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

We decided that the Plan does not have to pay for facet joint injections (64636) provided on October 28, 2019.
You asked the Plan to pay for the facet joint injections. 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 service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 64636 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure). 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 facet joint injections. Our reviewer says that CPT code 64636 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to support 2 units of Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) being preformed on October 28, 2019, therefore this service cannot be verified. 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64636) provided on October 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on January 14,
2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with the 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip falls within the
ambulance services 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 an ambulance trip
provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided from February 11, 2019 to June 10, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided from February 11, 2019 to June 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic procedure (97112) provided on February 18, 2019.
You asked the Plan to pay for the procedure. 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 units 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 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 procedure. Our reviewer says that CPT code 97112 does not meet criteria for billing or reimbursement consideration. Our reviewer found the Plan paid 3 units for 97112 and no additional documentation is noted to support additional units to be paid for this date of service. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic procedure (97112) provided on February 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a CYP gene panel provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the panel. You say that the Plan should reconsider coverage. The Plan denied your request. The Plan says the GYP gene panel is a single unit of service, and the single code used to report the CYP gene panel is not covered.
The Plan must follow Medicare rules. Medicare rules say that CYP gene panels are not covered. The services at issue in this were both not coded correctly, and not covered in the first place. Based on this information, we decided that Medicare rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for a CYP gene panel provided to the enrollee on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift provided January 2, 2020.
You asked the Plan to pay for the seat lift. You say that the seat lift is medically necessary. The Plan denied
your request. The Plan says rules for coverage were not met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
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 seat lift. Our reviewer says that coverage
criteria has not been met. Our physician reviewer found the record does not show severe arthritis or
neuromuscular disease. The record does not show that the enrollee is unable to stand from a regular chair. A
seat lift mechanism is not indicated.
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 lift have not been met. Therefore, we decided that the Plan does not
have to pay for a seat lift provided January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on December 4, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
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 office visit (99203) provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on February 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is include in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on January 16, 2020.
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physician's custom profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. 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 for the definitive drug testing provided on January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 19, 2019 to December 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services could have been provided in an observation setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the records show that it was not reasonable to expect that the enrollee's care would span more than two midnights. The enrollee's condition was stable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided December 19, 2019 to December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 20, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) bifocal lens (V2203) and anti-reflective lens (V2750) purchased October 31, 2019.
You asked the Plan to pay for the vision services. You say that you were told by the provider that you had a $150 credit towards a new pair of glasses. You had purchased a pair of lenses earlier that year and misplaced them and were never found. The Plan denied your request. The Plan says this request exceeds the benefit limit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eye wear. This benefit is allowed once every 24 months (2 years). Records show that this benefit was used December 17, 2018. This benefit will not be available until December 17, 2020.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) bifocal lens (V2203) and anti-reflective lens (V2750) purchased October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 7, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee went to the emergency department for concern for Pulmonary Embolism. The enrollee had several weeks of shortness of breath which worsened over the past week. The enrollee was discharged on the same day. The documentation does not support that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
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 lab work provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral feeding supplies (B4035, B4154) provided November 1, 2019 to November 30, 2019.You asked the Plan to pay for enteral feeding supplies. You say that this should be covered.The Plan denied your request. The Plan says a valid proof of delivery was not submitted.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. As a general Medicare rule, the date of service shall be the date of delivery.The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Although the items at issue were billed for dates of service November 1, 2019 to November 30, 2019, the delivery ticket in the file is for a delivery date of October 25, 2019. The items billed for November 1, 2019 to November 30, 2019 cannot be verified. Therefore, we decided that the Plan does not have to pay forenteral feeding supplies (B4035, B4154) provided November 1, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 10,
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 G0483 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 drugspecific
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; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not
include results for 22 or more drug classes. 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 G0483 provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 5, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the room through the entire procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device services coded 22854 provided on April 2, 2019.You asked the Plan to pay for the insertion of intervertebral biomechanical device 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 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure).We find that CPT code 22854 is not supported in the medical record. Specifically, the operative report did not include documentation of insertion of intervertebral biomechanical device(s) (synthetic cage, mesh), with integral anterior instrumentation for device anchoring (screws, flanges) when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, for each contiguous defect. Based on this information, we decided that Medicare rules for coverage of the insertion of intervertebral biomechanical device services have not been met.Therefore, we decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device services coded 22854 provided on April 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from September 9, 2019 to November 18, 2019.You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says only manual manipulation of the spine to  correct subluxation is covered.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 services at issue are not manual manipulation of the spine. Services other than manual manipulation of the spine to correct subluxation, when provided by a chiropractor are not covered. Therefore, we decided that the Plan does not have to pay for the medical services provided from September 9, 2019 to November 18, 2019.