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

We decided that the Plan does not have to pay for Oncotype DX testing (81519) provided on May 18, 2021. 
 
You asked the Plan to pay for Oncotype DX testing. You say that this is a covered service. The Plan denied 
your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Oncotype DX Breast was developed for patients 
with estrogen-receptor positive, node-negative carcinoma of the breast, estrogen-receptor positive 
micrometastases of carcinoma of the breast, and estrogen-receptor positive breast carcinoma with 1-3 positive 
nodes. The rules also say for 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. The submitted medical records do not document the determination of 
the enrollee?s node status. Without this information, it cannot be verified that the criteria for coverage have 
been met. Based on this information, we decided that Medicare rules for coverage of Oncotype DX testing have 
not been met. Therefore, we decided that the Plan does not have to pay for Oncotype DX testing (81519) 
provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (CPT code(s): 17000 and 99336) provided to the enrollee on July 13, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network services. You say that this is the contracted dermatologist for the facility. You state the provider should not be penalized for providing medical services. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 medical services (CPT code(s): 17000 and 99336) provided to the enrollee on July 13, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (CPT code 99204) provided to the enrollee on 
May 26, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network office services. You say that you are a specialty provider and 
were unaware that a referral was required. The Plan denied your request. The Plan says this provider is out-of-
network, the services were not referred by a network provider, and the services were not urgent or emergent, 
nor were they approved in advance. 
 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 office visit (CPT code 99204) provided to the 
enrollee on May 26, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95909) digital analysis of 
electroencephalogram (EEG) (95957) special electroencephalogram (EEG) tests (95958) provided November 
19, 2020. 
 
You asked the Plan to pay for the diagnostic testing. You say that the surgeon requested your services to be 
rendered during surgery. As the hospital does not have the staff or equipment, you provided the TC component 
of the CPT codes. The Plan denied your request. The Plan says the provider is not a recognized facility or a 
legally qualified physician and billing agents and third-party vendors do not fall within the category of eligible 
providers therefore, services are not payable under the plan.  
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, you provided services in the facility during and/or after surgery. Payment for this service would 
have been included under the facility claim. Payment for this service is the responsibility of the facility or 
hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of 
the diagnostic testing have not been met. Therefore, we decided that the Plan does not have to pay for nerve 
conduction studies (95909) digital analysis of electroencephalogram (EEG) (95957) special 
electroencephalogram (EEG) tests (95958) provided November 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services (CPT code (s): 90832 and 90847) 
provided from January 5, 2021, through March 1, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network mental health services. You say that the Plan paid for the 
same services from the same provider on a different date of service. You state the provider is in-network with 
the Plan. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in 
advance. The Plan states the previous claim was paid in error and that this provider is not in-network. 
 
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 mental health services (CPT code (s): 90832 
and 90847) provided from January 5, 2021, through March 1, 2021, by an out-of-network provider.
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 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.  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: 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 the complexity of your nursing, medical and rehabilitation needs do 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.  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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided from May 14, 2021, through July 19, 2021.  You asked the Plan to pay for the additional supplies and materials. You say that the office has taken additional steps in providing testing to ensure the continued safety of staff and patients. You say that the services were medically necessary and should be approved for payment. The Plan denied your request. The Plan says the office visits were paid, and the additional supplies and materials were denied as bundled services are not eligible for separate reimbursement.   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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from May 14, 2021, through July 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99443) provided on March 17, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available. 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services (99443) provided on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 17, 2021.

You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 81479 is not supported in the medical record. Specifically, the test was not signed by the enrollee's treating physician and the claim did not include the required Z code. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99443) provided on February 17, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.  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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services (99443) provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a cardiovascular stress test with ultrasounds, zoster (shingles) vaccination, and a cardiology office visit provided from March 4, 2021, to April 22, 2021.  You asked the Plan to pay for stress test, shingles vaccination, and specialist visit. You say that all you pay is the copayment for your yearly examinations. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct. The Plan also says that the denial of payment for the shingles vaccination is correct because this was not authorized.  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 $95 copayment for stress test at an outpatient hospital and $45 copayment for specialist visit. Your total copayment amount is therefore $140. Furthermore, in the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccination. The Plan follows the same rules.  You have been asked to pay $95 copayment for stress test and $45 copayment for specialist visit. Stress test and specialist visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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. Records do not show that you have been injured or directly exposed to any illness related to the singles vaccination. Therefore, we decided that the Plan does not have to pay for a cardiovascular stress test with ultrasounds, zoster (shingles) vaccination, and a cardiology office visit provided from March 4, 2021, to April 22, 2021.   Benefits for shingles vaccination 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for shoulder arthroscopy (29827), shoulder arthroscopy debridement (29823), and shoulder arthroscopy decompression (29826) provided on May 4, 2021.  You asked the Plan to pay for shoulder arthroscopy services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the records do not support the codes billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 29827 is arthroscopy, shoulder, surgical; with rotator cuff repair. The CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). The CPT Code Manual definition of code 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).  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 shoulder arthroscopy services. Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found the operative report does not describe a rotator cuff repair which consists of re-attaching tendon to bone; therefore, procedure code 29827 cannot be verified. The operative report does not meet criteria for extensive debridement, which includes anterior/posterior compartments; chondroplasty/bone debridement or soft tissues in areas other than primary procedure. Documentation does not document required criteria to verify extensive debridement code 29823 was performed. Code 29826 became an "add-on" code; therefore, an approved primary arthroscopy procedure must be performed in order to report this code.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for shoulder arthroscopy (29827), shoulder arthroscopy debridement (29823), and shoulder arthroscopy decompression (29826) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation and management services provided on May 29, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was processed correctly.  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 99236 is observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date. Usually the presenting problem(s) requiring admission are of high severity.    We find that CPT code 99236 is not supported in the medical record. The records show that the enrollee was referred to the hospital solely for the purpose of a transfusion. The records do not indicate the enrollee presented with a problem requiring an admission of high severity. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services provided on May 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a consultation on diagnostic services (D9310) provided on March 2, 2021.  You asked the Plan to pay for a consultation on diagnostic services. You say that you called the Plan prior to the date of service to verify if the services were covered. The Plan denied your request. The Plan says rules for payment have not been met.  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 a consultation on diagnostic services (D9310) provided on March 2, 2021.   Your complaint about receiving erroneous or incomplete information about your dental benefits from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided May 7, 2021 to May 20, 2021.  You asked the Plan to pay for the acupuncture services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met.  Specifically, the record shows the treatment was not for chronic low back pain. Therefore, we decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided May 7, 2021 to May 20, 2021.