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

 We decided that the Plan does not have to pay for the testing services coded as 95885, 95913, and 95955 provided on May 25, 2021.  You asked the Plan to pay for the testing services. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says the claim is not supported by the records provided.  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 definitions of the billed codes are as follows:   95885 -  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).  95913 -  Nerve conduction studies; 13 or more studies.  95955  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 the testing services. Our reviewer says that the documentation does not support the services performed as billed. Our reviewer found that the medical records provided do not include sufficient documentation to validate a that CPT 95885, 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) was the service that was performed on May 25, 2021, as pedicle screw stimulations are not baseline nerve conduction studies. Therefore, payment cannot be made for this incorrectly billed service. In addition, the medical records provided indicate a real time EEG was performed, which is not covered under CPT code 95955; therefore, this service cannot be verified. Finally, medical records indicate Train of Four testing was performed. Train of Four testing is not included in the code description for CPT 95913.  here is no specific code used to represent Train of Four testing as it is inclusive to intraoperative neuromonitoring (IONM), whether the IONM is primarily electromyography (EMG) based or motor evoked potentials (MEP) based. Therefore, 95913 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services coded as 95885, 95913, and 95955 provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (88120) provided February 8, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were for screening purposes and are non-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.  The test at issue in this appeal 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 lab services (88120) provided February 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 8, 2021.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concern that the this device is not as effective as surgical decompression, and lead to higher rates of reoperation.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Parkinson-Alzheimer-Dementia panel provided on December 17, 2020.

You asked the Plan to pay for the Parkinson-Alzheimer-Dementia panel. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says these services have not been billed according to Medicare guidelines.

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 Parkinson-Alzheimer-Dementia panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genomic testing has not been shown to lead to improved outcomes or significant changes in treatment for patients with a similar clinical presentation as this member. There was no exceptional circumstances that would justify this testing. 

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 Parkinson-Alzheimer-Dementia panel have not been met. Therefore, we decided that the Plan does not have to pay for the Parkinson-Alzheimer-Dementia panel provided on December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for a CT scan of the maxillofacial area (70486) provided on September 7, 2021, and a specialist physician office visit (99214) on September 30, 2021.  You asked the Plan to waive the copayments for a CT scan of the maxillofacial area and a specialist physician office visit. You say that both of these copayments will be hard for you to pay because of your job situation caused by a hurricane-related emergency. The Plan denied your request. The Plan says the correct copayments were 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 $180 copayment for advanced imaging services and a $40 copayment for consultation, diagnosis, and treatment by a specialist.   You have been asked to pay $133.59 for a CT scan of the maxillofacial area and a $40 copayment for a specialist physician office visit. A CT scan of the maxillofacial area falls into the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category and a specialist physician office visit falls into the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay less than or equal to the full and 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 copayments for a CT scan of the maxillofacial area (70486) provided on September 7, 2021, and a specialist physician office visit (99214) on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the interrogation device evaluation (G2066), provided on August 12, 2021.  You asked the Plan to waive the copayment for the interrogation device evaluation. You say that you should not have to pay a copayment. 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 $10 copayment for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $10 copayment for the interrogation device evaluation. 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 the interrogation device evaluation (G2066), provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special anesthesia services provided on July 13, 2021, billed with code 99100.  You asked the Plan to pay for the special anesthesia services. You say that you feel that this should be covered. The Plan denied your request. The Plan says it was decided to pay for codes 00537 and 36620; however, code 99100 is not payable.  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 99100 is Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).   This code has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is included in payment for the other services rendered. Medicare does not make additional payment for this service. Based on this information, we decided that Medicare rules for coverage of the special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on July 13, 2021, billed with code 99100.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 26, 2021, through August 27, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that she went to the emergency room because you were having difficulty breathing and chest pains. You say that this was an emergency and you needed help. The Plan denied your request. The Plan says the inpatient admission does not meet the MCG Health Inpatient & Surgical Care 25th Edition - Chest Pain ORG: M-89 (ISC) - Clinical indications for admission.   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 based on the medical records that you appeared to be hemodynamically stable with normal oxygenation on room air and acute coronary syndrome had been ruled out. Troponin trending and basic observation could have been completed at a lower level of care. It was not expected that you would require hospital care that would cross 2 midnights due to the low complexity and severity of this case.   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 from August 26, 2021, through August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for sedation services (99153) provided on June 9, 2021.  You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that services with status indicator N are paid under the Outpatient Prospective Payment System (OPPS), but their payment is packaged into payment for a separately paid service.  We looked at the file and Medicare rules. Code 99153 has a status indicator of N and is not separately payable. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on June 20, 2021, billed with code 81455.  You asked the Plan to pay for the F1Heme panel. You say that this testing has been validated by Medicare and cannot be denied. The Plan denied your request. The Plan says the use of code 81455 is not appropriate as this tests for more genes than are medically necessary.  The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with hematolymphoid conditions for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare.   We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on June 20, 2021, billed with code 81455.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for Radiologic examination, chest (71045) Computed tomography, thorax (71260) Radiologic examination, pelvis (72170) Computed tomography, abdomen and pelvis (74177) provided July 12, 2021.  You asked the Plan to pay for the diagnostic services. You say that claim denied as a duplicate in error. Please review and reprocess the claim for reimbursement according to contract. The Plan denied your request. The Plan says claim already processed.  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, we find that CPT code 74177, 71260, 71045 is not supported in the medical record. Specifically, the records supports that only one unit each of 74177-26, 71260-26, 71045-26 and 72170-26 which has already been previously approved and paid by the Plan on check dated 8/31/2021. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for Radiologic examination, chest (71045) Computed tomography, thorax (71260) Radiologic examination, pelvis (72170) Computed tomography, abdomen and pelvis (74177) provided July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for LTACH services provided from March 1, 2021, through April 22, 2021.  You asked the Plan to pay for the LTACH services. The Plan denied your request. The Plan says a LTACH admission was 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 pay for the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the LTACH for metastasis colon cancer and symptomatic management. Hospice care was discontinued. Recent notes show the enrollee was clinically stable with hemodynamic stability on oral midodrine, 3L oxygen, and oral antibiotics for a urinary tract infection. The enrollee appeared to be clinically stable on the oral medications and a lower level of care was most appropriate. The enrollee did not require services at the LTACH that would be available at a lower level of care facility. There were no services at the LTACH that the enrollee required that were not available and covered at a lower level of care.  LTACH treatment was not considered medically necessary as the enrollee's care was appropriate for 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for LTACH services provided from March 1, 2021, through April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the therapeutic radiology rendered on July 12, 2021.  You asked the Plan to waive the coinsurance for these services. You say that the coinsurance was applied correctly. The Plan denied your request. The Plan says you were not aware that the provider was out-of-network.  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 20% coinsurance for Medicare-covered therapeutic radiology services.     Review of the file shows that you received therapeutic radiology services from an out-of-network provider on July 12, 2021. Although the provider was out-of-network, the Plan agreed to process the claims with your in-network benefits. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered therapeutic radiology 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 coinsurance for the therapeutic radiology rendered on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urgent care office visit provided July 8, 2021.  You asked the Plan to waive the copayment for the office care. You say that your PCP was not available so you had to go to urgent care. If your PCP was available, your cost share would have only been $10. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.  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 $40 copayment for each covered office visit to other providers for urgently needed services for Urgently needed services.   You have been asked to pay $40 copayment for each covered office visit to other providers for urgently needed services for the office care. the office care falls within the Urgently needed 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 the urgent care office visit provided July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on April 10, 2021, and  April 11, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of the services.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.    We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for physician's services provided on April 10, 2021, and April 11, 2021.