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

We decided that the Plan does not have to pay for oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy (CPT code 81551) provided to the enrollee on July 12, 2021.
You asked the Plan to pay for the service. You say that this service should be covered based on Medicare guidelines. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the service. Our physician reviewer found the review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 service have not been met. Therefore, we decided that the Plan does not have to pay for oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy (CPT code 81551) provided to the enrollee on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 30, 2020.
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.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue (billed codes 81407, 81408,
81432, and 81479) has component test results and was not billed as one test under code 81479.
The rules say that, for edits with a modifier indicator of 0, the Column 2 code cannot be paid regardless of
whether a modifier is used.
The provider submitted a claim for procedure codes 81295 (MSH2 gene full sequencing), 81298 (MSH6 gene
full sequencing), and 81432 (hereditary breast cancer related disorders panel). Codes 81295 and 81298 are
column II codes with a modifier indicator of 0 when billed with column I code 81432. The column II codes are
not separately payable. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on July 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on September 1, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70551 (magnetic resonance imaging of the brain stem) and 70544 (MRA head). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. Therefore,
we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on September 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

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 procedure codes 97112 and 97140 are not supported.
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 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The definition of code 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. We find that CPT codes 97112 and 97140 are not supported in the medical record.
Specifically, there is no documentation of a therapeutic procedure to one or more areas for 15 minutes was performed to support code 97112. There is no documentation of manual therapy techniques to one or more regions for 15 minutes to support code 97140. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the stereoscopic x-ray guidance rendered on June 16, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes G6002 (stereoscopic x-ray guidance) and 77014 (computed tomography scan for therapy guidance). Code G6002 is a column II code with a modifier indicator of 1 when billed with column I code 77014. Code G6002 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the stereoscopic x-ray guidance rendered on June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the exchange of an intraocular lens (66986)
provided on July 20, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $200
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital
facility.
You have been asked to pay a $200 copayment for the outpatient surgery provided at an ambulatory surgical
center. 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 the exchange of an intraocular
lens (66986) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oxygen concentrator received on June 29, 2021.  You asked the Plan to pay for the oxygen concentrator. You say that your oxygen machine had broken and you had to replace it. You also say that you feel the Plan should reimburse you 50% for this item. The Plan denied your request. The Plan says the items received are not a covered benefit when purchased.  The Plan must follow Medicare rules. The rules say that oxygen and related oxygen supplies are only covered when rented. Payment is not made for the purchase of these items.  We looked at the file and Medicare rules. Review of the file shows that you purchased an oxygen concentrator and lifetime warranty. Payment cis not made for purchases of this type of equipment. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator received on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from March 9, 2021, to March 16, 2021, and the outpatient surgery provided from May 6, 2021, to May 7, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services and outpatient surgery. You say that you cannot pay these bills. 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 $295 copayment per day for days 1-5 for inpatient hospital services and $0 per day after day 5. Your contract also says that you must pay a $295 copayment for surgery and other services provided at an outpatient hospital.  The record shows you were in the hospital from March 9, 2021, to March 16, 2021. You have been asked to pay $1475 for the first five days for inpatient hospital services ($295 copayment x 5 days = $1475). Inpatient hospital services fall within the Inpatient Hospital Care benefit category.   The record also shows you had an outpatient procedure from May 6, 2021, to May 7, 2021. You have been asked to pay a $245 copayment for the outpatient procedure. However, the record shows a $245 adjustment has been applied to this copayment, leaving a remaining balance of $50.  The total for both visits is $1525. 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 inpatient hospital services provided from March 9, 2021, to March 16, 2021, and the outpatient surgery provided from  May 6, 2021, to May 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on April 12, 2021 and billed under codes 95955 and 95927.
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 Medicare billing criteria are not met.
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 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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found for code 95955 the technical report documents "real time" monitoring, which should not be reported with this code. In addition, code 95955 is considered "special EEG tests", and the technical report does not include documentation to support additional EEG testing was performed. For code 95927 the technical report does not document SSEP stimulation in trunk or head. Unable to cite report, as this procedure is not documented.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for diagnostic services provided to the enrollee on April 12, 2021 and billed under codes 95955 and
95927.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the diagnostic colonoscopy you had at an ambulatory surgery center on August 9, 2021.  You asked the Plan to waive the cost sharing for the diagnostic colonoscopy. You say that you have never been charged for colonoscopies in the past. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  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 20% coinsurance for outpatient surgery after your $200 deductible is met.   Records show that you had a diagnostic colonoscopy performed due to diverticulosis. You have been asked to pay a $200 deductible and 20% coinsurance for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery 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 cost sharing for the diagnostic colonoscopy you had at an ambulatory surgery center on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 1, 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 supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on May 1, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on April 6, 2021.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiologist visit provided on July 7, 2021.
You asked the Plan to waive the copayment for a cardiologist visit. You say that you did not have a visit with the cardiologist. 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 $40 copayment for each office visit with a specialist provider. The medical records show you received services from the cardiologist. You have been asked to pay a $40 copayment for a cardiologist visit. A cardiologist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a cardiologist visit provided on July 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on July 28, 2021.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you had a normal yearly mammogram done and it was not an ultrasound. You said that you had last year's mammogram on July 27, 2020, so more than a year had passed between the two. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $20 copayment for ultrasounds. We reviewed the medical records to confirm what services you had. The medical records from the July 28, 2021, date of service confirm that you had an ultrasound of the upper outer quadrant of your right breast. You have been asked to pay a $20 copayment for the breast ultrasound. 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 the breast ultrasound you had on July 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care after an elective arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve 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 that based on the medical records provided there is no documentation
that the admitting physician reasonably expects that the enrollee's necessary hospital care will span two
midnights. The medical records do not document any medically unstable conditions.
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 pre-approve acute inpatient hospital care after an elective arthroplasty, knee, condyle and
plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) surgery
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission 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 that based on the medical records provided, 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 require physical therapy and occupational therapy services
but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 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 IRF admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on June 22, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says the Plan eyewear benefits have been exhausted.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every 2 years. We looked at the file and the Plan's rules. The file shows that the Plan paid for contact lenses prescribed on
March 31, 2020, which means you have exhausted the routine eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine eye exam and eyeglasses
You asked the Plan to pre-approve the routine eye exam and eyeglasses. You say that you lost your glasses, and they are nowhere to be found. You say that you cannot see anything. The Plan denied your request. The Plan says your benefit for the requested services/items is currently exhausted.
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 covers up to one routine eye exam per year. The Plan covers up to one pair of complete
eyeglasses every year.
We looked at the file and the Plan's rules. The records show that you received coverage for a routine eye exam
and eyeglasses on November 12, 2021. This means that your benefit for these types of services in the 2021
calendar year is currently exhausted. Based on this information, we decided that the Plan's rules for coverage of
the routine eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to
pre-approve a routine eye exam and eyeglasses