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 21, 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 criteria of this code. The documentation shows test results for only 18 drug classes. 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 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management coded 99217
provided on June 28, 2021.
You asked the Plan to pay for the observation care discharge day management. You say that you would like
this claim reprocessed for payment. The Plan denied your request. The Plan says the services billed 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 99217 is observation care discharge day management
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital
"observation status" if the discharge is on other than the initial date of "observation status."
To report services to a patient designated as "observation status" or "inpatient status" and discharged on the
same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge
Services, 99234-99236 as appropriate.]).
We find that CPT code 99217 is not supported in the medical record. Specifically, the qualifying initial (99218-
99220) or subsequent observation care (99224-99226) was not found in the documentation. This means this
code is not payable. Based on this information, we decided that Medicare rules for coverage of the observation
care discharge day management have not been met. Therefore, we decided that the Plan does not have to pay
for the observation care discharge day management coded 99217 provided on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory surgical boot (L3260), and office visit
(99214), provided on August 12, 2021.
You asked the Plan to pay for the surgical boot and office visit. You say that you need these items. The Plan
denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
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 $35
copayment for each visit to a specialty physician office.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. You have been asked to pay a $35 copayment for a specialty physician office visit. This service falls
within the Physician/Practitioner services, including doctor's office visits benefit category. Therefore, we
decided that the Plan does not have to pay for the ambulatory surgical boot (L3260), and office visit (99214),
provided on August 12, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for PCD (CPT code E0675) and segmental gradient pressure pneumatic appliance (CPT code E0673-NU, RT and E0673-NU, LT) provided to the enrollee on June 3, 2021.
You asked the Plan to pay for the DME. You say that according to the enrollee's condition, the therapy is the most effective treatment to prevent cost and potential life-threatening complications. The Plan denied your request. The Plan says the DME is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that the DME was billed with an incorrect place of service. Review of the claim summary shows that CPT code E0673
was billed with place of service 24 (Ambulatory Surgical Center). According to the Medicare Claims Processing Manual Chapter 20, section 10.1 and 10.2, the DME must be for use in the patient's residence other than a healthcare institution and payment cannot be made for equipment for use in an institution. Furthermore, the CPT code E0675 billed on this claim is not covered by Medicare; therefore, it is not covered by the enrollee's healthcare plan. A PCD provides intermittent limb compression. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. A PCD coded as E0675 to treat peripheral artery disease is not eligible for reimbursement. Claims for E0675 will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pay for PCD (CPT code E0675) and segmental gradient pressure pneumatic appliance (CPT code E0673-NU, RT and E0673-NU, LT) provided to the enrollee on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy coded 29823 provided on April 27, 2021.
You asked the Plan to pay for the shoulder arthroscopy. 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 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]). We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report did not include documentation to meet the guidelines of a surgical shoulder arthroscopy, with extensive debridement, including 3 or more discrete structures (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]); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy coded 29823 provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser-assisted cataract surgery.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have glaucoma and require cataract surgery; however, the records do not support that the laser-assisted surgery is needed. The laser-assisted cataract surgery is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve laser-assisted cataract surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (CPT code 99285) provided to the enrollee on October 8, 2020.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

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 service. Our reviewer found the review indicates that the enrollee was evaluated for complaints of vertigo. Review of the medical records indicates that the evaluation did not include medical decision making of high complexity. for CPT code 99285. The review has determined that the service was not supported by the medical records provided for review. 

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 service have not been met. Therefore, we decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (CPT code 99285) provided to the enrollee on October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from May 26,
2020, through May 29, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for
reconsideration. The Plan denied your request. The Plan says the determination to remove secondary diagnosis
code J18.9, from the claim is upheld.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with J18.9 - pneumonia, unspecified organism. 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 inpatient hospital care. Our physician reviewer found the
review has determined that diagnosis code J18.9 was not supported by the records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided to the enrollee from May 26, 2020, through May 29,2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 20,
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 the medical 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.
We find that the various denied codes are not supported in the medical record. Specifically, the place of service
on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim
reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a
doctor's office (POS 11). 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 laboratory services
provided to the enrollee on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82036) provided March 30, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this service was not billed with a valid diagnosis code and was for screening
purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (82036)
provided March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies and materials (CPT code 99070) provided to the
enrollee on February 9, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. CPT code 99070, which has a status indicator of
'B' on the CMS Physician Relative Value File and is always bundled into payment for other services not
specified and no separate payment Is made per Medicare. This claim has not been billed with an appropriate
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for supplies and materials (CPT code 99070) provided
to the enrollee on February 9, 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 these services are medically necessary. The Plan denied your request. The Plan says that records do not show you need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.

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. With your current medical stability, and no complex medical problems, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs. You do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from continued physical and occupation therapy your rehab needs can be safely met in an alternate and low intensity setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on July 26, 2021.

You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was billed without a modifier as required by Medicare 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads;
interpretation and report only (CPT code 93010) provided to the enrollee on January 1, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. Our records indicate a NCCI
Procedure to Procedure (PTP) edit exists between 93010 and 36556. This PTP edit has a modifier indicator of
1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was
not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for
electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010)
provided to the enrollee on January 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64447 provided on November 30, 2020.

You asked the Plan to pay for the injection 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. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64447 for the injection services is a column II code to column I code 01480. This claim has not been billed with an appropriate modifier to bypass the edit. In addition, the medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64447 provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540,
83550, 83970, 84100) provided to the enrollee on April 7, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. The provider reported
routine lab services related to the treatment of end stage renal disease (ESRD), which does not follow industry
standard coding rules. Therefore, we decided that the Plan does not have to pay for the laboratory services
(CPT code(s): 82310, 82728, 83540, 83550, 83970, 84100) provided to the enrollee on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (CPT code 76942) provided to the enrollee on June 15, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says experimental or investigational services are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The rules say that use of the following CPT Codes for these treatments is inappropriate and will be denied: CPT code 76942- ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (CPT code 76942) provided to the enrollee on June 15, 2021