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

We decided that the Plan does not have to pay forthe surgical services rendered on March 4, 2020.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 30140 is not supported.The Plan mustfollow 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 30140 is submucous resection inferior turbinate, partial or complete, any method.We find that CPT code 30140 is not supported in the medical record. Specifically, the operative report does not contain documentation of a partial or complete submucosal resection of the inferior turbinate.Codes 43200 and 31525-59 are not separately payable because they are inclusive to another billed code.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 surgical services rendered on March 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electroencephalogram (95812) and neuromuscular junction testing (95937) provided on June 24, 2019.You asked the Plan to pay forthe electroencephalogram and neuromuscular junction testing. 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.In this case, the CPT Code Manual definition of code 95812 is electroencephalogram (EEG) extended monitoring; 41-60 minutes.The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.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 electroencephalogram and neuromuscular junction testing. Our reviewer says that CPT codes 95812 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that an Electroencephalogram (EEG) extended monitoring; 41-60 minutes was performed on June 24, 2019. Our reviewer found CPT code 95937 does not meet criteria for billing or reimbursement consideration. The medical documentation provided indicates the Train Of Four testing was performed which does not meet the description represented by CPT code 95937, therefore it is inappropriate to bill 95937.
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 electroencephalogram and neuromuscular junction testing have not been met.Therefore, we decided that the Plan does not have to pay forthe electroencephalogram (95812) and neuromuscular junction testing (95937) provided on June 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, prothrombin time, and phlebotomy services received on January 10, 2020 by an out of network (OON) provider. You asked the Plan to pay for the office visit, prothrombin time, and phlebotomy services. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services received are not a covered benefit when received by an OON provider. 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 office visit, prothrombin time, and phlebotomy services received on January 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided on September 11, 2020.You asked the Plan to pay forthe Guardant360 testing. You say that you would like reconsideration because this testing is necessary to match the member with the appropriate pharmaceutical product to successfully treat their disease.The Plan denied your request. The Plan says there is clinical evidence that the cancer has evolved wherein testing would be performed for a different genetic content.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 Guardant360 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewerfound there is no clinical information provided to justify this test.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 Guardant360 testing have not been met.Therefore, we decided that the Plan does not have to pay forGuardant360 testing provided on September 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for Solution 100 units (CPT Code J0585) and
administration (64615).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the enrollee hasn't tried one of the preferred drugs, Dysport or Xeomin.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant
Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our
physician reviewer found the Plan requires a trial of drug Dysport or Xeomin before they will approve the
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no
documentation provided indicating that the Plan's required drug(s) likely be less effective and/or likely have
adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we
decided that the Plan does not have to pre-approve Botox for Solution 100 units (CPT Code J0585) and
administration (64615).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam with refraction (92014 and 92015) provided on
October 5, 2020.
You asked the Plan to pay for eye exam with refraction. You say that the service should be covered. The Plan
denied your request. The Plan says the copayment for eye exam with an ophthalmologist was applied correctly
and you received a refraction from a non-preferred provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers refractions with preferred providers and there is a $20 copayment for eye exams with
ophthalmogists.
We looked at the file and the Plan's rules. The eye exam with an ophthalmologist cost share was applied
correctly and you received the refraction from a non-preferred provider and therefore, the service is not
covered. Based on this information, we decided that the Plan's rules for coverage of eye exam with refraction
have not been met. Therefore, we decided that the Plan does not have to pay for eye exam with refraction
(92014 and 92015) provided on October 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on September 17, 2020.You asked the Plan to waive the copayment fora colonoscopy. You say that this was a screening. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient surgery/in-network. You have been asked to pay a $100 copayment for a colonoscopy. Evidence was provided that polyps were found and removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removalshould be billed.A colonoscopy falls within the outpatient surgery/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and
first intraoral periapical x-ray (D0220) provided on August 31, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray.
You say that you would like to appeal these services. The Plan denied your request. The Plan says your third
quarter comprehensive dental benefit allowance was exhausted.
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, the Plan offers up to a $100.00
allowance for comprehensive dental services every quarter. The Plan contract says that after plan paid benefits
for comprehensive dental services, you are responsible for the remaining costs. The record shows that you met
the annual maximum benefit on July 22, 2020 and your annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation
(D0140) and first intraoral periapical x-ray (D0220) provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings,The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transportation service (A0429), ambulance mileage (A0425), and ambulance supplies (A0422) provided on April 8, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says an Explanation of Benefits statementfrom the primary insurance company is needed before the claim can be reprocessed. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the provider severaltimes advising to bill the primary insurance companyfor these services. The provider indicated they would bill the primary insurance. As the secondary insurer, the Plan cannot be held responsible until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe ambulance transportation service (A0429), ambulance mileage (A0425), and ambulance supplies (A0422) provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis is covered when specific criteria 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of high-grade serous carcinoma of the left ovary and fallopian tube. The documentation does not support that alternative 
laboratory or clinical tests to definitively diagnose the disorder/identify the condition are unavailable or results are clearly equivocal. The testing was therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on March 10, 2020.You asked the Plan to pay forthe dental service. You say that the service should be covered.The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services provided during open treatment of femoral shaft fracture with plate/screws, with or without cerclage on June 1, 2020.You asked the Plan to pay forthe assistant surgeon 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 27507 is open treatment of femoral shaft fracture with plate/screws, with or without cerclage.We find that the assistant surgeon services for CPT code 27507 arenot supported in the medical record. Specifically, the documentation submitted did not include documentation of an operative note indicating the assisting surgeon's name and credentials. Based on this information, we decided that Medicare rules for coverage of the assistant surgeon services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided during open treatment of femoral shaft fracture with plate/screws, with or without cerclage on June 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit coded 99285, the cardiopulmonary resuscitation services coded 92950, and the intubation services coded 31500 provided on August 22, 2020.You asked the Plan to pay forthe emergency department visit, the cardiopulmonary resuscitation services, and the intubation services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 codes 99285, 92950, and 31500 are not supported in the medical record. Specifically, these services were billed with diagnosis codes I46.8 (Cardiac arrest due to other underlying condition) as the primary diagnosis and codes J98.9 (Respiratory disorder, unspecified) and E66.01 (Morbid (severe) obesity due to excess calories). Diagnosis code I46.8 is a secondary diagnosis code and was reported as the primary code for these services, which is invalid. Based on this information, we decided that Medicare rules for coverage of the emergency department visit, the cardiopulmonary resuscitation services, and the intubation services have not been met. Therefore, we decided that the Plan does not have to pay forthe emergency department visit coded 99285, the cardiopulmonary resuscitation services coded 92950, and the intubation services coded 31500 provided on August 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after January 29, 2021.
You asked the Plan to pre-approve the continuation of SNF services. The Plan denied your request. The Plan
says that the enrollee's needs are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF services. Our
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a
nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated
for a UTI. Regarding rehabilitation services, the enrollee received physical therapy (PT). By the dates in
question, the enrollee was at minimal to maximal assist level with bed mobility and transfers and she was nonambulatory
at baseline. There are no identifiable skilled nursing service needs. There are no identifiable skilled
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a
practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the continuation of SNF services have not been met. Therefore, we decided that
the Plan does not have to pre-approve continuation of SNF services after January 29, 2021.