Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676).  You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on May 5, 2021.  You asked the Plan to pay for CxBladder testing. You say that this is a covered service. The Plan denied your request. The Plan says this is experimental.  The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on December 17, 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 were not billed correctly.  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 has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for esophagogastroduodenoscopy services (procedure code 43247) provided to the enrollee on May 28, 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 claim does not follow industry standard coding rules.

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 43247 is "Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)." 

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 procedure report does not document that foreign body was removed, and therefore the procedure as coded cannot be verified. The services performed should be reported to the highest specificity. Therefore, there is a more appropriate CPT code to support services 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for esophagogastroduodenoscopy services (procedure code 43247) provided to the enrollee on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mechanical traction (97012) therapeutic procedure (97112) cold laser therapy (97039) and physical therapy re-evaluation (97164) provided on April 22, 2021 to May 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that you have tried different therapies including cortisone shots, different doctors and pain management. Chiropractic care was the only thing that helped you. You feel that this is your last resort and it should be covered. 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. The Plan only covers manual manipulation of the spine to correct subluxation.  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 mechanical traction (97012) therapeutic procedure (97112) cold laser therapy (97039) and physical therapy re-evaluation (97164) provided on April 22, 2021 to May 19, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the Parasympathetic Function and Sympathetic Function Test (95943), provided on November 21, 2019.  You asked the Plan to waive the copayment for the Parasympathetic Function and Sympathetic Function Test. You say that there shouldn't be a copayment. The Plan denied your request. The Plan says the cost share was applied 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 $225 copayment for diagnostic procedures and tests for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $225 copayment for diagnostic procedures and tests for the Parasympathetic Function and Sympathetic Function Test. This service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 the Parasympathetic Function and Sympathetic Function Test (95943), provided on November 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from January 1, 2019, to January 15, 2019.

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 there are inconsistencies between the documentation in the medical records and the coding of the
Minimum Data Set (MDS) assessments.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

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 documentation is insufficient to
support the coding of pneumonia or oxygen use, for the dates January 1, 2019, to January 15, 2019.

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 skilled nursing facility (SNF) services provided to the enrollee from January 1, 2019, to January
15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone graft (D7950), provided on June 17, 2021.  You asked the Plan to pay for the bone graft. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone graft (D7950), provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) provided on March 29, 2021.  You asked the Plan to waive the copayment for EGD. You say that you are on a limited income and your financial situation does not allow you to pay this. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  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 $225 copayment for EGD at an ambulatory surgical center.   You have been asked to pay $225 copayment for EGD. EGD falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for wound debridement provided on April 12, 2021.  You asked the Plan to waive the copayment for the wound debridement. You say that you were in a regular exam room and not a surgical room. 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 for surgery or other services provided at an outpatient hospital.   You have been asked to pay a $295 copayment for the wound debridement. Please note that any procedure involving tissue removal is considered a surgical procedure, regardless of the procedure location. The wound debridement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a mastoidectomy (69222) provided on March 24, 2021, and June 22, 2021.  You asked the Plan to waive the copayment for the mastoidectomy. You say that the services should be covered because they used to be covered in 2020 under a different code. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 2021 plan benefits and services 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 $75 copayment for Outpatient hospital services.     You have been asked to pay a $75 copayment for two mastoidectomies. The record indicates that these services were performed in an outpatient setting. Mastoidectomies fall within the Outpatient hospital services 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 mastoidectomy (69222) provided on March 24, 2021, and June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination (71045) provided on January 8, 2021.

You asked the Plan to pay for X-Ray exam. You say that you are appealing with records to support this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan already paid for 1 unit of 71045 and the record does not support a second unit.

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 71045 is radiologic examination, chest; single view. 

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 X-Ray exam. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found 1 unit of 71045-26-77 was billed and paid by the Plan on February 12, 2021. The records do not include sufficient documentation to validate that a second unit of 71045-26-77 was performed on January 8, 2021; therefore, this code cannot be verified.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of X-Ray exam have not been met. Therefore, we decided that the Plan does not have to pay for an X-Ray examination (71045) provided on January 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical spine x-ray rendered on May 25, 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 procedure code 72040 is 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 72040 (cervical spine x-ray, 2-3 views) and 72052 cervical spine x-ray, 6 or more views). Code 72040 is a column II code with a modifier indicator of 1 when billed with column I code 72052. Code 72040 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 cervical spine x-ray rendered on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for epidurography (72275) provided on April 6, 2021.

You asked the Plan to pay for epidurography 72275. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code
is inclusive to code 64483, and the record does not support the -59 modifier.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service. Specifically, the record does not support that this epidurography was a separate, distinct procedure
from the primary transforaminal epidural procedure. Based on this information, we decided that Medicare rules
for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does
not have to pay for epidurography (72275) provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series
of intraoral x-rays (D0210), and prophylaxis (D1110) provided on September 1, 2021, by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and
prophylaxis. You say that you would like this denial to be reconsidered because these services were critical for
someone in your age group. The Plan denied your request. The Plan says services performed by an OON
provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you
did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis
(D1110) provided on September 1, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint (64625) provided on June 16, 2021.  

You asked the Plan to pre-approve RFA to the SI joint. You say that these services were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of RFA to the SI joint is not proven.

  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 RFA to the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the performed SI joint RFA 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint (64625) provided on June 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 27, 2020, to July 31, 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 there are inconsistencies between the documentation in the medical records and the coding of the 5 day Minimum Data Set (MDS) assessment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  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 although the medical records support a diagnosis of urinary tract infection, the case file does not contain physician documentation of malnutrition.  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 skilled nursing facility (SNF) services provided to the enrollee from July 27, 2020, to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia for transurethral procedures (00914) and anesthesia for patient of extreme age (99100) provided on November 23, 2020.  You asked the Plan to pay for the anesthesia services. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says the documentation does not support the services as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). The CPT Code Manual definition of code 00914 is anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate  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 anesthesia services. Our reviewer says that the documentation does not support the billed code 00914. Our reviewer found 50 units of 00914 have been billed.   The anesthesia report documents an anesthesia start time "16:31", and anesthesia end time "16:21" performed on November 23, 2020. Documentation does not support anesthesia was provided over 23 hours. Documentation is not clear on start and stop times. Anesthesia time is reported in minutes. One unit of time is reported for each 15-minute increment of anesthesia time. In this case no units of service can be verified, as documentation is not clear.  We find that CPT code 99100 is not eligible for payment. Specifically, this code has a status code of "B" under the Physician Fee Schedule. This means that payment for covered services are always bundled into payment for other services not specified and no separate payment is made.  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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for transurethral procedures (00914) and anesthesia for patient of extreme age (99100) provided on November 23, 2020.