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

 
We decided that the Plan does not have to pay for outpatient therapy (97530) provided September 28, 2021. 
 
You asked the Plan to pay for the outpatient therapy. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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 97530 is not supported in the medical record. Specifically, the service was performed in 
the home setting by a therapy assistant. There is a more appropriate CPT code to describe this service (G0158). 
Based on this information, we decided that Medicare rules for coverage of the outpatient therapy have not been 
met. Therefore, we decided that the Plan does not have to pay for outpatient therapy (97530) provided 
September 28, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 31, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the 
emergency room and had your temperature, blood pressure and oxygen level taken but did not see a doctor. You 
also say that after sitting in triage for 45 minutes you left. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for an in-network emergency room visit.  
 
The records show you were triaged in the emergency room on August 31, 2021. You have been asked to pay 
the allowed amount of $67.29, which is less than the $90 copayment for an emergency room visit. An 
emergency room visit falls within the Emergency Care 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 emergency room visit provided on August 
31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrectomy (43621) provided on April 28, 2021.
You asked the Plan to pay for the gastrectomy (43621). You say that you are a hospitalist who was asked to
assist in this emergency case. The Plan denied your request. The Plan says procedure code 43621 is not
supported in the medical records.
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 43621 is gastrectomy, total; with Roux-en-Y reconstruction.
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 gastrectomy (43621). Our reviewer says that the
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that
the operative report does not describe a total gastrectomy, as the whole stomach removal was not documented.
Therefore, this procedure would not be covered.
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 gastrectomy (43621) have not been met. Therefore, we decided that the Plan
does not have to pay for the gastrectomy (43621) provided on April 28, 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 this is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the review has determined that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve grocery delivery service.
You asked the Plan to pre-approve the grocery delivery service. You say that this service is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not
covered. The plan provides a supplemental benefit for grocery box delivery for some enrollees. The enrollee
must be diagnosed with both diabetes and depression.
We looked at the file and Medicare rules. The record does not show a diagnosis of both diabetes and
depression. Based on this information, we decided that Medicare rules for coverage of the grocery delivery
service have not been met. Therefore, we decided that the Plan does not have to pre-approve grocery delivery
service.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.
You asked the Plan to pre-approve Feraheme. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Feraheme. Our reviewer says that the medication is not medically necessary. Our physician reviewer found there is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Injection(s), anesthetic agent(s) and/or steroid; sciatic
nerve (64445) provided on June 15, 2021.
You asked the Plan to pay for code 64445. 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. 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 64445 is a column II code to column I code 01480. 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 Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve (64445) provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Drainage of peritoneal abscess or localized peritonitis
(49020) provided on January 21, 2021.
You asked the Plan to pay for code 49020. 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. 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 49020
is a column II code to column I code 44143. 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 Drainage of peritoneal abscess or localized peritonitis
(49020) provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided May 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that the procedure was medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Comprehensive Genetic Panel, service 
providers should use 1 unit only of procedure code 81479 (used for the entire bundled multi-test panel) at this 
time, not unbundled to separate codes. 
 
 
 
 
 We looked at the file and Medicare rules. In this case, unbundled codes were billed for a single testing panel. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided May 
28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic services (97530) provided on September 25, 2021.
You asked the Plan to pay for the therapeutic 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. Medicare rules say that the services of an OTA 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 occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner,
and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for the therapeutic services (97530) provided on September 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met based on the results of the last injection received. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESI may be considered when the medical 
record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline.    
 
 
 
 
 
 
  
 
We looked at the file and Medicare rules. In this case, the documentation specifically indicates that although 
the pain relief was 85% after the last ESI, the pain returned to baseline within 4 days. Based on this 
information, we decided that Medicare rules for coverage of a repeat epidural steroid injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related 
group (DRG) code 853. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 853. The Plan denied your 
request. The Plan says DRG 853 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 DRG 853: Infectious and parasitic diseases with 
O.R. procedure with mcc. 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 
hospital services billed with DRG 853. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found the medical records do not support the billing of the the billed DRG 853. The 
proposed downgraded DRG 854 is correct.  
 
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 billed with diagnosis related group (DRG) code 853.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76700) provided on November 1, 2021. 
 
You asked the Plan to pay for code 76700. 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. 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 76700 
is a column II code to column I code 93976. 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 Ultrasound (76700) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass frames (V2020), anti-reflective coating (V2750) 
and a spherocylinder single vision lens (V2103) provided on September 14, 2021. 
 
You asked the Plan to pay for eyeglass frames, anti-reflective coating and a single eyeglass lens. You say that 
you do not understand how your benefit is exhausted when you have not had new eyeglasses for three years. 
You also say you should be able to purchase new glasses when needed. The Plan denied your request. The Plan 
says you exhausted your benefit allowance, and you are responsible for the remaining balance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says that you receive a $250 allowance every calendar year that you can use to pay 
for eyewear to correct vision. 
 
We looked at the file and the Plan's rules. The records show you exhausted your $250 maximum allowed 
benefit on September 14, 2021. The records also show that you purchased frames at an allowed amount of 
$125, a spherocylinder single lens at an allowed amount of $269 and anti-reflective coating at an allowed 
amount of $20. The Plan applied your $250 allowance leaving a balance of $164 ($125 + $269 + $20 = $414 - 
$250 = $164). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, anti-
reflective coting and single eyeglass lens have not been met. Therefore, we decided that the Plan does not have 
to pay for eyeglass frames (V2020), anti-reflective coating (V2750) and a spherocylinder single vision lens 
(V2103) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on May 21, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this service is not billable. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 27, 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. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 27, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (CGM) and related supplies for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no trial and failure of the preferred product line.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no reason given as to why the Freestyle Libre would not suffice. This will also give alerts for high or low blood glucose levels. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (CGM) and related supplies for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 27590) provided to the 
enrollee on August 3, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this procedure requires that a qualifying procedure be received and covered. 
 
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 27590 is "Amputation, thigh, through femur, any level." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report does not include 
enough information to confirm the reason for unplanned return to operating room during post operative 
period. To cite the report "Indications for procedure: The patient is a 79-year-old gentleman who has had 
previous revascularizations without improvement in his distal blood flow. He has a nonhealing wound.  He was 
offered amputation for a nonhealing wound. He was agreeable to proceed". In this case no documentation was found to support a previous revascularization to confirm a global period.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 27590) provided to the enrollee on August 3, 2021.