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

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 8, 2021.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by 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. In this case, the CPT Code Manual definition of code G0483 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; 22 or
more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 22 or more drug classes to support the coding of this code. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) device (K0553) and
supplies (K0554), provided on June 1, 2021.
You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet the criteria for these items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided
that the Plan does not have to pay for the continuous glucose monitor (CGM) device (K0553) and supplies
(K0554), provided on June 1, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on June 28, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that by the
time the ambulance arrived you thought you were alright and did not want to go to the hospital. The Plan
denied your request. The Plan says this service is not a covered benefit under your plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 28, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no
transport (A0998) provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 20, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 71045 is not supported in the medical record. Specifically, this code was billed with place of service 22 (outpatient hospital); however, the documentation shows that the enrollee was inpatient for this date of service. This means that this code was billed with an incorrect place of service. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 12, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by 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 code 71045 is not supported in the medical record. Specifically, this code was billed with
place of service 22 (outpatient hospital); however, the documentation shows that the enrollee was inpatient for
this date of service. This means this code was billed with an incorrect place of service. Based on this
information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore,
we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99307) provided on March 15, 2021 to March 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the services provided are medically necessary services for patients in the skilled nursing facility during their convalescence. The enrollee has no choice which physicians render services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 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 subsequent nursing facility care (99307) provided on March 15, 2021 to March 17, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
You asked the Plan to pre-approve a Vertiflex Superion interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex Superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion Interspinous device at L2-3 is not medically reasonable or 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 a Vertiflex Superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 6, 2021 to
May 10, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found based on the patient improving with initial treatment in the emergency room and
without severe disease or failure of outpatient treatment noted on workup, it was expected that this patient
would require hospital services that would not likely cross 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided May 6, 2021 to May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99334) provided on April 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeing reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 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 domiciliary or rest home visit (99334) provided on April 10, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from April 26, 2020, to April 30, 2020, and billed with code IACD1.
You asked the Plan to pay for SNF care. You say that this was billed correctly. The Plan denied your request. The Plan says that the enrollee was not in isolation and was not diagnosed with chronic respiratory failure.
The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF Patient-Driven Payment Model (PDPM) prospective payment system (PPS). Under this system, each digit of the Health Insurance Prospective Payment System (HIPPS) code corresponds to a different case-mix group aspect of the SNF care provided. We looked at the file and Medicare rules. Based on the PDPM calculations worksheet and the conditions reported by the SNF, the billed HIPPS code is correct. The records show that the enrollee had the diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure, corresponding to an NTA score of 3. The records also show that the enrollee was placed in isolation due to an active coronavirus diagnosis. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided from April 26, 2020, to April 30, 2020, and billed with code IACD1.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid coded 87481 provided on May 25, 2021.
You asked the Plan to pay for infectious agent detection by nucleic acid. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by 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. In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique. We find that CPT code 87481 is not supported in the medical record. Specifically, the documentation does not support that four units of this service were provided on the billed date of service. The documentation does not contain the results of this testing. Based on this information, we decided that Medicare rules for coverage of infectious agent detection by nucleic acid have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid coded 87481 provided on May 25, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on June 22, 2021 by an out-of-network (OON) provider.
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 services were rendered by an out-of-network provider without prior authorization.
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 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 the pathology services provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on January 26, 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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 

We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on January 26, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on June 24, 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 the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on June 24, 2021.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 1, 2020 to November 6, 2020.
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 the claim was missing the visit with an appropriate G code for the billed dates of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. A review of the file shows that the claim was not reported correctly. 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 home health services provided to the enrollee from November 1, 2020 to November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared laser therapy provided out of network from April 13, 2021 to June 1, 2021.
You asked the Plan to pay for this treatment. You say that this treatment should be covered by the Plan. The Plan denied your request. The Plan says this treatment is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover infrared laser treatment therapy. Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that outpatient therapeutic services require prior authorization.
You received infrared laser therapy out of network without prior authorization. This treatment is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for infrared laser therapy provided out of network from April 13, 2021 to June 1, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May
11, 2021.
You asked the Plan to pay for the dental service. You say that you moved recently. You say that you are further
away from your previous dentist now. You say that you were not comfortable being around unmasked people
on public transportation so you found a dentist office closer to you. You also say that this service should be
covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan
years. The Plan also says that the frequency limit has been exceeded.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The
record shows that the Plan paid for a comprehensive oral evaluation that you received on December 4, 2019.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150)
provided on May 11, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 CDx testing (0242U) provided on April 11, 2021.
You asked the Plan to pay for Guardant360 CDx testing. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 CDx testing (0242U) provided on April 11, 2021.