Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran inpatient consultation (99254) provided on March 15, 2020.You asked the Plan to pay foran inpatient consultation. You say that this was an emergency service.The Plan denied your request. The Plan says this service is not covered under Medicare.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 99254 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an inpatient consultation have not been met.Therefore, we decided that the Plan does not have to pay foran inpatient consultation (99254) provided on March 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing coded 81120, 81121, 81173, 81201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, and 81403 provided on February 25, 2020.You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denialThe 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 81120, 81121, 81173, 81201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, and 81403 are not supported in the medical record. Specifically, this service should be coded with CPT 81479. In addition, the appropriate DEX Z Code identifier must be entered adjacent to the CPT code in the comment/narrative field. 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 for the Guardant360 testing coded 81120, 81121, 81173, 81201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, and 81403 provided on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on April 9, 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 the services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that an OPPS payment status indicator is assigned to every HCPCS code. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 01402. This code has an OPPS status indicator of C and is an inpatient procedure that is not payable under OPPS. 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 anesthesia services rendered on April 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 27, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
codes cannot be verified.
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 drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on June 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested LTACH admission is medically necessary.The Plan denied your request. The Plan says the requested LTACH admission is not medically necessary.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 admission is not medically necessary. Our physician reviewer found theenrollee is with protracted hospitalization with bowel obstruction, laparotomy, and development of c-diff colitis. The enrollee is not on vent. Does not need complex wound management, and is taking food orally. Providers feel she is too high level for short term acute care and request long term acute care as possible solution for inability to place in short term care.The enrollee does not meet criteria for LTACH. The enrollee does not have complex wound or ventilator care. The enrollee does not need medications that are intravenous and require monitoring. The enrollee is at an appropriate level of care and can transition to short term rehab in the future.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does nothave to waive the cost-sharing forBotox (J0585) and chemodenervation (64616) provided on February 27, 2020.You asked the Plan to waive the cost-sharing forBotox and chemodenervation. You say that you have never been charged for Botox when you received injections in the past.The Plan denied your request. The Plan says these services processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B drugsand pay a $25 copayment for surgery services provided in a specialist's office.You have been asked to pay $489.60($2,448 allowed amount x 20% coinsurance = $489.60) for Botox, a Medicare Part B drug,and $25 for chemodenervation, a surgical service provided in a specialist office. 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 cost-sharing forBotox (J0585) and chemodenervation (64616) provided on February 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided by an out-of-network provider
on March 24, 2020.
You asked the Plan to pay for practitioner visit. You say that the enrollee was seen by your provider at the
request of the nursing home. The Plan denied your request. The Plan says the denial of payment for this service
is correct, because this provider is out-of-network with the Plan and the referring provider is also out-ofnetwork
with the Plan.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for a practitioner visit provided by an out-of-network provider on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services(CPT 88346 and CPT 88350) provided to the enrollee on October 30, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the medical records do not provide documentation to support a separate and distinct service as described by CPT 88350 and 88346 was performed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of the denied codes is:CPT 88350:Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)CPT 88346:Immunofluorescence, per specimen; initial single antibody stain procedure We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided do in include documentation to validate that CPT 88350 and 88346 were performed as distinct separate services, therefore these service cannot be verified and are not eligible for reimbursement consideration.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for lab services (CPT 88346 and CPT 88350) provided to the enrollee on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for DecisionDx-Melanoma testing(81599).You asked the Plan to pay for Decision DX-Melanoma testing. You say that you would like reconsideration because the testing services were medically necessary.The Plan denied your request. The Plan says the testing does not meet LCD criteria.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 DecisionDx-Melanoma testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the pathology report results indicated a histologic type of superficial spreading with a Breslow thickness of 0.30mm; ulceration, regression, and lymphatic invasion were not identified; mitotic rate is less than one mitosis/mm2 with involvement of the peripheral margin present and no deep involvement. These results were classed as a stage T1aNxMx.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 DecisionDx-Melanomatestinghave not been met.Therefore, we decided that the Plan does not have to pay for DecisionDx-Melanoma testing (81599).provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on February 25, 2020.You asked the Plan to waive the copayment for the specialist office visit. You say that you did not see any doctor. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit medical records to support that you saw a doctor at the specialist office visit. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the specialist office visit provided on February 25, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe transportation services.You asked the Plan to pre-approvethe transportation services. You say that the transportation is medically necessary because you need to be transported to and from dialysis treatments.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pre-approve are wheelchair van transport services.Therefore, we decided that the Plan does nothave to pre-approvethe transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea walk-in shower.You asked the Plan to pre-approvea walk-in shower. You say that youcannot get into the bath tub.The Plan denied your request. The Plan says a walk-in shower is considered a convenience item primarily hygienic in nature and not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that walk-in showers are not covered because they are not primarily medical in nature. While a walk-in shower may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Also, Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to pre-approvea walk-in shower.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 5, 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. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 140mg Repatha Sureclick.
You asked the Plan to pre-approve the Reptha. You say that you would like reconsideration because this drug is
medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's
condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 140mg Repatha Sureclick.
Benefits for the Reptha may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past
medical history of dementia, atrial fibrillation and hypothyroidism who presented to the acute hospital on
07/14/2020 with a fall and left hip (intertrochanteric) fracture. She underwent surgical repair of the fracture in
the hospital with some reported post-operative delirium. She is weak and deconditioned and is working with
physical and occupational therapy though reports indicate she has been uncooperative with therapy at times.
She is walking 40 feet with a rolling walker with minimum assistance and is minimum to moderate assist for
most transfers and activities of daily living. She is medically stable.
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does require physical therapy and occupational therapy services but based on the medical records
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the
medical records provided there is concern that the enrollee will not be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe over-bed table (E0274).You asked the Plan to pre-approvethe over-bed table. You say that you are appealing the denial of the over the bed table. You are bed bound and you need it.The Plan denied your request. The Plan says this is a convenience item and is not covered under Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvethe over-bed table (E0274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on October 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for 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. In this case, the CPT Code Manual definition of HCPCS code J2353 is "Injection, octreotide, depot form for intramuscular injection, 1 mg." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found this HCPCS code J2353 has a Status Indicator of K and was submitted without an associated OPPS procedure, therefore does not meet the Medicare rule for payment consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).You asked the Plan to pre-approve the total electric hospital bed. You say that you are appealing the denial and the records provided will show proof of medical necessity.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composites for tooth #'s 22, 26 and 27 provided on March 10, 2020.You asked the Plan to pay forthe resin-based composites for tooth #'s 22, 26 and 27. You say that you have medical problems that caused you to have more frequent cavities. You say that a small cavity should be paid for now instead of waiting for a bigger problem.The Plan denied your request. The Plan says only two filling procedures are covered per calendar year.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 Planoffers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit of two filling procedures per calendar year. The Plan paid for two fillings on March 10, 2020, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay forthe remaining resin-based composites for tooth #'s 22, 26 and 27 provided on March 10, 2020.