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

We decided that the Plan does not have to pay for procedure code 99214 billed for date of service September 1,
2020.
You asked the Plan to pay for procedure code 99214. You did not provide an argument with your appeal
request. The Plan denied your request. The Plan says this code is included in the global surgical package.
The Plan must follow Medicare rules. Medicare rules say that preoperative visits on the day of surgery for
minor procedures are included in the global surgical package and are not separately payable.
Records show that you performed a minor surgery (procedure code 31231) on the same date as the evaluation
and management code in dispute here. You did not bill procedure code 99214 with a modifier that would
indicate that it was unrelated to the surgery. Because no modifier was billed, we can only assume that 99214 is
related to the surgery performed and is therefore considered part of the global surgical package. We looked at
the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of
procedure code 99214 have not been met. Therefore, we decided that the Plan does not have to pay for
procedure code 99214 billed for date of service September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the total knee arthroplasty (27447-AS) provided on August 2, 2021.   

You asked the Plan to pay for the total knee arthroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the assistant surgical services were performed by a Surgical Technologist/Surgical First Assistant (CST/CSFA).  

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the total knee arthroplasty (27447-AS) provided on August 2, 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 is not medically necessary.  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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI).  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 services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic neck pain treated with medical therapy and physical therapy. She had a intralaminar ESI on January 7, 2022 with 50 percent improvement in pain relief. The pain improvement did not last for at least three months. The enrollee does not meet the criteria for coverage of a repeat ESI and the services are therefore not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 20, 2021.  You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the service billed.  The Plan must follow Medicare rules. Medicare rules say that Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care provided from March 9, 2020, to March 20, 2020.  You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of the primary diagnosis code is supported. The Plan denied your request. The Plan says the billing of primary diagnosis code, A41.9, Sepsis, unspecified organism, is not supported.  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 primary diagnosis code, A41.9, defined as Sepsis, unspecified organism. 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 an additional amount for the inpatient care. Our reviewer says that the billing of the primary diagnosis code is not supported. Our physician reviewer found the provided documentation did not include clinical or laboratory evidence of sepsis. Therefore, the reviewer found that the billing of primary diagnosis code, A41.9, Sepsis, unspecified organism, has not been 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 an additional amount for the acute inpatient hospital care provided from March 9, 2020, to March 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided August 1, 2021 to August 18, 2021.  You asked the Plan to pay for the SNF services. You say that the Plan should cover for the SNF services provided. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.  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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided August 1, 2021 to August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0482) provided on February 16, 2021.  

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the physician order submitted is incomplete.  

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the documentation submitted does not include a valid physician order. Of note, the order in the file is not signed. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on February 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.  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 services are not medically necessary.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi level mild to moderate foraminal narrowing without moderate central canal stenosis. The record does not document that the enrollee is not indicated for operative intervention at no more than two levels. The services are therefore not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service July 26,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and they
should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for
these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 62320 billed for date of service July 26, 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 January 15, 2021.  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted 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 code is not appropriate for 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 physician assistant, 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 January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endovenous ablation therapy (36475-79) provided on September 25, 2021.  You asked the Plan to pay for the endovenous ablation therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says modifier 79 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 36475-79 is not supported in the record. Specifically, the documentation submitted does not support the use of modifier 79. The record submitted does not show that a previous 0, 10 or 90-day post-operative procedure was billed during its applicable post-operative period by the same provider. Based on this information, we decided that Medicare rules for coverage of the endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the endovenous ablation therapy (36475-79) provided on September 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on October 1, 2021.
You asked the Plan to pay for the behavioral health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 25, 2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.
The Plan must follow Medicare rules. Medicare rules say that The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 11,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and they
should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for
these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record s not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 62320 billed for date of service October 11, 2021
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extremity study (93971) provided on September 18, 2021.  You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 93970 and 93971.  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 have confirmed that code 93971 is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the extremity study (93971) provided on September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 2,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and they
should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for
these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 62320 billed for date of service August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81321, 81206, 81210, 81235, 81272,
81275, 81276, 81301, and 81311) provided on July 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT
codes describing the component test results.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have
to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 81311)
provided on July 12, 2021.