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

We decided that the Plan does not have to pay for the definitive drug testing rendered on February 12, 2021.
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 procedure code G0483 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes.
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that testing of 22 or more classes was performed. 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 definitive drug testing rendered on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (20930, 20936) provided  
July 2, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20930, & 20936 is not supported in the medical record. Specifically, the medical 
records provided do not include sufficient documentation to validate that an Allograft, morselized, or 
placement of osteopromotive material, for spike surgery only, was performed.  The medical records provided 
do not include sufficient documentation to validate that an Autograft for spine surgery was performed. Based 
on this information, we decided that Medicare rules for coverage of the surgical services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical services (20930, 20936) provided  
July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 21, 2020 to November 25, 2020.
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 submitted records do not support the billing of diagnosis codes I13.0 and J96.21.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnoses I13.0 (Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease) and J96.21 (acute and chronic respiratory failure with hypoxia). 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 submitted records do not support the billing of diagnosis codes I13.0 and J96.21. Our physician reviewer found the enrollee was admitted with acute congestive heart failure exacerbation. The emergency room record did not contain documentation stating a diagnosis of chronic kidney disease. The history and physical did not contain documentation stating a diagnosis of chronic kidney disease. The Cardiology consultation note dated November 25, 2020 states that the enrollee has a history of chronic kidney disease with hypertensive heart disease and also notes stage II chronic kidney disease. The diagnosis of chronic kidney disease was not stated within the Infectious Disease or hospitalist progress notes. The discharge summary did not contain documentation stating a diagnosis of chronic kidney disease. The diagnosis of chronic kidney disease was not stated clearly or consistently throughout the submitted medical record. Diagnoses I13.0 and J96.21 are not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from November 21, 2020 to November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and urinalysis provided on October 19, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and urinalysis. You say that the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit and urinalysis provided on October
19, 2020, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on September 28, 2021 with altered mental status attributed to intercranial hemorrhage and underwent a 
decompressive craniotomy with resection. The records show that her current care needs are custodial in nature. 
She has no skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. As a practical matter, the enrollee 
does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the porcelain crown (D2740) provided on March 24, 2021.
You asked the Plan to waive the cost share amount for the dental service. You say that there was an added charge of $200 for a porcelain crown that you were not informed of. You say that you feel you should have been informed of this before the work was completed. You say that you should not be responsible for this. The Plan denied your request. The Plan says you received a porcelain crown. The Plan says that you have coverage for a high noble metal crown. The Plan says that you are responsible for the difference in the costs, or $32. The Plan also says that this is explained in the Certificate of Coverage.
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, you are responsible for the different in cost for any optional treatment. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share amount for the porcelain crown (D2740) provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on June 10, 2021.
You asked the Plan to waive the copayment for an epidural injection. You say that you disagree with how high the charges are for a simple injection. You state that you were told your copayment would be a lot less. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received an epidural injection at an outpatient hospital facility on June 10, 2021. Epidural injections are considered outpatient surgical procedures. Therefore, you are responsible to pay the $390 copayment. You have been asked to pay a $390 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 epidural injection provided on June 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on
April 30, 2020 and billed with a Patient-Driven Payment Model (PDPM) of KAXE1 for 1 day.
You asked the Plan to pay for the skilled nursing facility (SNF) care. You say that the records support that the enrollee had both cerebrovascular disease and malnutrition. The Plan denied your request. The Plan says the records do not support that the enrollee had both cerebrovascular disease and malnutrition.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our 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 skilled nursing facility (SNF) care. Our reviewer says that the records do not support that the enrollee had both cerebrovascular disease and malnutrition. Our reviewer found the reviewed documentation did not support the coding of the Primary diagnosis of 167.9, malnutrition and all Section GG payment items which results in the reduction of PT/OT, nursing and NTA components of the PDPM Score. There was no physician documented diagnoses of cerebrovascular disease and malnutrition received. The review has determined that the records did not support that the enrollee had both Cerebrovascular disease and malnutrition. 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 skilled nursing facility (SNF) care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on April 30, 2020 and billed with a Patient-Driven Payment Model (PDPM) of KAXE1 for 1 day.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 24, 2020, by an outof-
network (OON) provider.
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 24, 2020,
by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker.
You asked the Plan to pre-approve the heavy duty walker. You say that the enrollee requires the heavy duty wheelchair for its size. The Plan denied your request. The Plan says the enrollee weighs under 300 pounds, therefore is the heavy duty wheelchair is not covered.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker (E0148, E0149) is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. The enrollee does not meet the weight requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the heavy duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for transcutaneous electrical nerve stimulation (TENS) unit (code E0730) provided on July 19, 2021.
You asked the Plan to waive the deductible for the TENS unit. You say that you are unable to afford this if it is not covered by insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to durable medical equipment.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable Medical Equipment and Related Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the TENS unit was received on July 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for transcutaneous electrical nerve stimulation (TENS) unit (code E0730) provided on July 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95937, 95927, and 95907 provided on June 2, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says the medical records do 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 codes 95955, 95885, 95937, 95927, and 95907 are: 95955 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 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) 95937 - Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 95927 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 95907 - Nerve conduction studies; 1-2 studies 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 medical services. Our reviewer says that the documentation does not support the codes billed. Our reviewer found that CPT 95955 is not support by the technical report as there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for "real time" monitoring. For CPT 95885, all criteria for this report is not supported by the technical report, as nerve conduction studies are a criteria for this procedure, which cannot be confirmed as performed. Regarding CPT 95937, the technical report does not document neuromuscular junction testing was performed, and therefore cannot be confirmed. Unable to cite report as this procedure is not documented. Regarding CPT 95927, the technical report does not document Somatosensory Evoked Potentials (SSEP) study, recording from the central nervous system, trunk or head. Unable to cite report as this procedure was not documented and cannot be confirmed as performed. Finally, for CPT 95907 the technical report does not include documentation of nerve conduction studies and therefore cannot be confirmed as performed. Procedure describes pedicle screw stimulation, which is inappropriate to code CPT 95907 for this procedure. 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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95937, 95927, and 95907 provided on June 2, 202
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from June 8, 2021, through June 9, 2021, billed with secondary diagnosis code N13.8.
You asked the Plan to pay for the inpatient care as billed. You say that it is felt that this claim was billed correctly, and that all reported diagnoses are supported. The Plan denied your request. The Plan says the diagnosis code N13.8 is not supported which reduces the DRG payment for this admission.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis code N13.8, defined as Other obstructive and reflux uropathy. 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 inpatient care as billed. Our reviewer says that the documentation does not support reporting code N13.8 as a secondary diagnosis on this claim. Our physician reviewer found the documentation indicates that the history and physical notations stated a diagnosis of "obstructive uropathy on the right side with hydronephrosis due to a 6mm renal stone" within the problem list. The diagnosis of obstructive uropathy is not stated within the progress notes, consultation notes, procedure note, or the discharge summary. A diagnosis of obstructive uropathy is not stated clearly or consistently throughout the submitted medical record nor is it stated at the time of discharge. The review has determined that the documentation did not support the inclusion of diagnosis code N13.8 as an additional diagnosis for this inpatient admission. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from June 8, 2021, through June 9, 2021, billed with secondary diagnosis code N13.8.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two cataract surgeries you had on June 23, 2021, and July 7, 2021, and at ambulatory surgery center.
You asked the Plan to waive the copayments for the two cataract surgeries. You say that you were told this would be covered by insurance. You said that you were not informed of these copayments before you had the surgeries. The Plan denied your request. The Plan says you were charged these copayments 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 $100 copayment per visit for outpatient surgery at an ambulatory surgery center. You have been asked to pay a $100 copayment per visit for the two cataract surgeries. The two cataract surgeries fall within the outpatient surgery at an ambulatory surgery center 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 copayments for the two cataract surgeries you had on June 23, 2021, and July 7, 2021, and at ambulatory surgery center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve the power mobility device. You say that the enrollee needs the PMD, the
manual wheelchair and crutches he uses are no longer enough for mobility. The Plan denied your request. The
Plan says the documentation is insufficient to support medical necessity; specifically, no home assessment was
performed.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 power mobility device. Our
reviewer says that the service is not shown in the documentation to be medically necessary. Our physician
reviewer found the documentation does not indicate that the enrollee is having problems doing his MRADLs in
the home; cannot use a walker or manual wheelchair or scooter to do his MRADLs in the home; can safely use
a PMD; or that a home evaluation was done to show the PMD will fit and can be used in the home.
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 power mobility device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a power mobility device.