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

We decided that the Plan does not have to pay for the Guardant360 testing coded 81402, 81400, 81321, 81275, 81270, 81235, and 81210 provided on May 13, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81402, 81400, 81321, 81275, 81270, 81235, and 81210 are not supported in the medical record. Specifically, the procedures are mutually exclusive to already approved and reimbursed procedures paid by the Health Plan. Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome.
Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing coded 81402, 81400, 81321, 81275, 81270, 81235, and 81210 provided on May 13, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan (virtual colonography) for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this denial is appropriate given the clinical scenario.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a colonoscopy was attempted on July 6, 2021 but proved incomplete. However, the procedure was terminated due to the limited preparation. The procedure was not due to obstructing neoplasm, intrinsic scarring, stricture, aberrant anatomy, diverticular disease, extrinsic compression, or obstruction caused by radiation or surgery. The standard of care warrants a repeat colonoscopy attempt after optimal (two-day lavage) preparation. CT colonography is not medically necessary at this time. Indeed, were CT colonography performed and not normal, an ideally-prepped colonoscopy would still be warranted. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan (virtual colonography) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued services of an HHA (G0156) and direct skilled nursing services of a RN (G0299).
You asked the Plan to pre-approve the continued services of an HHA and direct skilled nursing services of a RN. The Plan denied your request. The Plan says you do not meet the guidelines for coverage of continued HHA services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued services of a HHA and direct skilled nursing services of a RN. Our reviewer says that the requested services are not shown to be medically necessary or reasonable. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer found that you do not have documented skilled therapy needs. Our physician reviewer also found that your care needs appear to be custodial. 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 continued services of a HHA and direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued services of an HHA (G0156) and direct skilled nursing services of a RN (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 and the advance care planning services coded 99497 provided on February 8, 2021.

You asked the Plan to pay for the initial hospital care services and the advance care planning services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not supported in the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 99223 and 99497 are not supported in the medical record. Specifically, the documentation does not support initial hospital care services or advance care planning services were provided on this date of service. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services and the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 and the advance care planning services coded 99497 provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you feel this item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve the Durolane. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.
The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Durolane. Our reviewer says that Durolane is not approved, as step criteria have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires that these drugs be trialed first. Our reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered. 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc or Synvisc-one (J7325).
You asked the Plan to pre-approve the Synvisc or Synvisc-one. You say that the enrollee has completed a course of physical therapy and Cortisone injections to the affected hip. The Plan denied your request. The Plan says there is not enough evidence at this time that demonstrates efficacy/success of this treatment for the indication of hip osteoarthritis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Synvisc or Synvisc-one. Our reviewer says that Synvisc or Synvisc-one (J7325) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Synvisc or Synvisc-one is not FDA-approved for the enrollee's diagnosis. Our reviewer also found that its use is not supported by one of the major drug compendia or by clinical research that appear in a Centers for Medicare & Medicaid Services approved medical journal. 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 Synvisc or Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc or Synvisc-one (J7325).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for percutaneous vertebral augmentation
provided on April 27, 2021.

You asked the Plan to waive the copayment for percutaneous vertebral augmentation. You say that you
disagree with the charges because you were not informed that you would owe anything. 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 $275
copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You have been asked to pay $175, which is less than the $275 copayment for percutaneous vertebral
augmentation. Percutaneous vertebral augmentation 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 percutaneous vertebral augmentation provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 23, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you met the 2020 MOOP amount prior to receiving the services. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay the MOOP amount for 2020 is $6,700. The enrollee's contract with the Plan also clearly says that enrollees must pay a $50 copayment for specialist services. 

The enrollee had a specialist visit on March 23, 2020. The record shows that the enrollee has only paid
$3,811.02 toward the $6,700 in-network MOOP amount for 2020 prior to receiving the services. Therefore, the enrollee is responsible to pay the $50 copayment. 

The enrollee has been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 51785, 95908, 95927, 95937 and 95955 billed on March 4, 2021.

You asked the Plan to pay for the medical services coded as 51785, 95908, 95927, 95937 and 95955. You say that the medical records support these services as billed. The Plan denied your request. The Plan says the submitted documentation does not support 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 the following codes is provided below:

95955 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
51785 - Needle electromyography studies (EMG) of anal or urethral sphincter, any technique
95937 - Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
95908 - Nerve conduction studies; 3-4 studies 
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 

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 coded as 51785, 95908, 95927, 95937 and 95955. Our reviewer says that the medical records do not support the codes as billed. Our reviewer found the enrollee is an 81-year-old female who received medical services on March 4, 2021. For the code billed 95955, the medical report documents real time monitoring. This service would be included in the primary code for intraoperative neuromonitoring. Therefore, this code would not be separately reported. The technical report does not document needle or sponge electrode was inserted into anal canal to perform Anal Sphincter electromyography (EMG); therefore, this procedure cannot be confirmed as performed. For the code 95937, the technical report does not document neuromuscular Junction testing; therefore, this procedure cannot be confirmed as performed. Regarding CPT 95908, the technical report documents "Pedicle Testing" was performed. Nerve conduction studies are performed with electrodes placed directly over the nerve. Therefore, this procedure would not be covered. Finally, for code 95927, the technical report documents Ulnar nerve stimulation was performed, CPT 95927 is inappropriate code to report 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 coded as 51785, 95908, 95927, 95937 and 95955 have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 51785, 95908, 95927, 95937 and 95955 billed on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planning (D4341 x2) provided on May 11, 2021.
You asked the Plan to pay for periodontal scaling and root planning. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planning (D4341 x2) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 7, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 laboratory testing 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 the laboratory services provided on November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the mattress provided on September 24, 2020.

You asked the Plan to pay for the services provided. You say that the product was obtained for treatment of your orthopedic condition. The Plan denied your request. The Plan says the services do not serve a primarily medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the mattress provided on September 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided
February 24, 2021.

You asked the Plan to pay for the psychotherapy services. You say that as evidenced by the attached medical
records, your physician only provided medically necessary services to the enrollee in good faith, and the
services rendered meet professionally recognized standards of healthcare. The Plan denied your request. The
Plan says services are not supported without the required documentation.

The Plan must follow Medicare rules. Medicare rules say that Medicare payment for clinical psychologist's
services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the
State, with patient consent, and consult with the attending or primary care physician. We looked at the file and
Medicare rules. The documentation shows that the claim does not include a referring provider. There is also no
indication in the medical records that the provider reached out to the enrollee's primary care physician. Based
on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been
met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90832)
provided February 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no noted skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 12, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test coded G0482 provided on July 1, 2020.
You asked the Plan to pay for the drug test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test coded G0482 provided on July 1, 2020