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

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87498, 87631, 87798, 87486, 87541, 87581, and 87640) provided to the enrollee on August 23, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a skilled nursing facility POS 31. Also, the laboratory results submitted indicate the specimen was collected on August 23, 2020, and received by the lab on August 25, 2021. Of note, the enrollee resides in Florida (FL) and the billing laboratory is located in Texas (TX); therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87498, 87631, 87798, 87486, 87541, 87581, and 87640) provided to the enrollee on August 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on November 14, 2020.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93010 and 12013. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on November 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies (95908), and an electroencephalogram (95955) on August 24, 2021.

You asked the Plan to pay for needle electromyography, nerve conduction studies, and an electroencephalogram. You say that these codes are supported in the records. The Plan denied your request. The Plan says these codes are not documented.

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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude, and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of 95908 is nerve conduction studies; 3-4 studies. The definition of 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). 

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 needle electromyography, nerve conduction studies, and an electroencephalogram. Our reviewer says that these codes are not supported in the records. Our reviewer found the documentation does not support nerve conduction studies. "Sub-dermal needle electrodes" would not be used when performing nerve conduction studies, which measure latency, amplitude, and conduction velocity. Therefore, both 95885 and 95908 are not supported. In regard to 95955, the documentation supports "real time" monitoring. Code 95955 is inappropriate for this 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 needle electromyography, nerve conduction studies, and an electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies (95908), and an electroencephalogram (95955) on August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to reduce the amount they are charging for an inpatient hospital stay. We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with these charges. The Plan says that inpatient hospital care.

We decided that the Plan has to reduce the amount they are charging for an inpatient hospital stay.

The Plan follows Medicare rules. Medicare rules say that you cannot be charged more than $1,400 ($490 x 3 days = $1,400) for an inpatient hospital stay. Therefore, we decided that the Plan has to reduce the amount they are charging for an inpatient hospital stay.

We also decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

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 $490 copayment per day for days 1-3. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,400 ($490 x 3 days = $1,400). Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

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: 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 requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion/specialty drug administration (CPT code(s) 99601 and, 99602) provided to the enrollee from March 30, 2021, through March 31, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. CPT code(s): 99601 and 99602 are assigned a status code I = Not valid for Medicare purposes. Therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for home infusion/specialty drug administration (CPT code(s) 99601 and, 99602) provided to the enrollee from March 30, 2021, through March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular genetic risk assessment panes (CPT code(s): 81442 and 81479) provided to the enrollee on May 28, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

Medicare denies coverage for all cardiovascular genetic risk assessment panels. Medicare only covers a lipid panel consisting of a total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride once every five (5) years as cardiovascular screening. The test at issue in this appeal, the services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic risk assessment panes (CPT code(s): 81442 and 81479) provided to the enrollee on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code 80307) provided to the enrollee on March 30, 2021.

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says CPT code 80307 has not met the associated frequency relationship criteria.

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 drug testing. Our physician reviewer found the documentation indicates that CPT code 80307 has not met the associated frequency relationship criteria. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code 80307) provided to the enrollee on March 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76882), provided on August 4, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay a copay. The Plan denied your request. The Plan says the cost share was applied correctly.

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 $60 ultrasound copayment for outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $60 ultrasound copayment for an ultrasound. This service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound (76882), provided on August 4, 2021.
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 requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or in home with therapies with family support.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF treatment and care to help with his physical condition and mental health, along with his overall wellbeing and to avoid more falls/hospital time. The Plan denied your request. The Plan says clinical criteria for coverage of SNF care have not been met.

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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was alert with confusion. The enrollee received physical therapy. The enrollee was at a minimal/moderate to contact guard assist level for functional mobility. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine received on July 22, 2021

You asked the Plan to pay for the services. You say that you did not ask for the vaccine and cannot afford the responsibility. The Plan denied your request. The Plan says immunization administration and the vaccine itself are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine received on July 22, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy; flexible, diagnostic, including collection of specimen(s) by brushing or washing, when performed.

You asked the Plan to pre-approve a colonoscopy. You say that a colonoscopy is medically necessary. The Plan denied your request. The Plan says a colonoscopy is not medically necessary.

The Plan follows Medicare rules. 

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 a colonoscopy. Our reviewer says that a colonoscopy is not medically necessary. Our physician reviewer found the provided documents do not support that you meet the Medicare LCD coverage requirements for diagnostic colonoscopy at this time. You are an average risk and without red flag signs nor symptoms.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy; flexible, diagnostic, including collection of specimen(s) by brushing or washing, when performed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 26, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. In this case, the claim provided lists a place of service as an independent laboratory. The records do not indicate the enrollee's specimen was obtained at the independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307, 82542, 84228, G0483) rendered by the out-of-network (OON) provider on July 6, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 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 the laboratory services (80307, 82542, 84228, G0483) rendered by the out-of-network (OON) provider on July 6, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve an MRI. You say that the enrollee was referred to a neurologist who requested the imaging prior to seeing her. The Plan denied your request. The Plan says that there is no plain x-ray following the enrollee's spine surgery, as the initial evaluation.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found plain films of the thoracic and lumbar spine were done with reports in the chart on June 28, 2021. The enrollee continues to have back pain and there is concern about fracture at L3 on clinical grounds. Plain films were done in June 2021 revealing no compression fracture. It would seem appropriate to forego another set of plain films and the enrollee's continued tenderness at L3 is of concern. She has a history of multiple sclerosis (MS) as well. Since a fall was documented the requirement of physical therapy in this patient with MS is not 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 an MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve diagnostic MBBs at two levels bilaterally. We decided that the
Plan does not have to pre-approve MBBs at more than two levels.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that
the services are not medically necessary.
We decided that the Plan has to pre-approve diagnostic MBBs at two levels bilaterally.
The rules say that MBBs are covered at two levels bilaterally 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 pre-approve these services. Our reviewer says that
MBBs at two levels are medically necessary. Our physician reviewer found the enrollee has chronic low back
pain. She had radiofrequency ablation at four levels bilaterally in 2018 and again in 2019. The Medicare
criteria limits MBBs to two levels bilaterally per sessions. Two levels are reasonable and medically necessary.
We looked at this physician's review, the file, and Medicare rules. The physician states that the services are
medically necessary at two levels. Based on this information, we decided that Medicare rules for coverage of
these services have been met. Therefore, we decided that the Plan has to pre-approve diagnostic MBBs at two
levels bilaterally.
We also decided that the Plan does not have to pre-approve MBBs at more than two levels.
We looked at this physician's review, the file, and Medicare rules. The physician states that the services are not
medically necessary at more than two levels. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve
MBBs at more than two levels.