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

We decided that the Plan has to pay for drug tests, definitive 22+ classes (G0483) and drug tests, presumptive (80307) provided on May 13, 2021.
You asked the Plan to pay for drug tests, definitive 22+ classes and drug tests, presumptive. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We asked our coding 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 drug tests, definitive 22+ classes and drug tests, presumptive. Our reviewer says that the services are supported by the medical records. Our coding reviewer found the documentation submitted was reviewed and does meet criteria. For code G0483, laboratory report documents over 22 drug classes for definitive drug screen and therefore would be covered. For code 80307, laboratory report documents 3 drug classes tested for presumptive testing and therefore would be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of drug tests, definitive 22+ classes and drug tests, presumptive have been met. Therefore, we decided that the Plan has to pay for drug tests, definitive 22+ classes (G0483) and drug tests, presumptive (80307) provided on May 13, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound repair services provided on April 9, 2021, billed with code 12011.
You asked the Plan to pay for the wound repair as billed. You say that this should be paid. The Plan denied your request. The Plan says code 12011 is 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 12011 is Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less.
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 wound repair as billed. Our reviewer says that the code 12011 is not supported. Our reviewer found the procedure report documents "The nasal bridge abrasion/laceration was closed with glue after cleaning". This procedure is considered a tissue adhesive. Medicare payors will recognize the wound repair codes as long as tissue adhesive is used in combination with sutures or staples. However, if the provider used only tissue adhesive to close the wound, G0168 Wound closure utilizing tissue adhesive(s) should be used. 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 wound repair as billed have not been met. Therefore, we decided that the Plan does not have to pay for the wound repair services provided on April 9, 2021, billed with code 12011.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services (CPT 90999) provided from
February 1, 2020 to February 29, 2020.
You asked the Plan to pay for dialysis services. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We asked our coding 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 dialysis services. Our reviewer says that the services are not supported by the medical records. Our coding reviewer found the documentation submitted was reviewed and does not meet criteria.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services (CPT 90999) provided from February 1, 2020 to February 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled therapy to
establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any
skilled services on an inpatient basis, at a SNF level of care as of November 11, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on October 14, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says that the provider at issue is not contracted with the Plan for medical services, there was no authorization on file and no referring provider. The Plan also says there are contracted network physicians who can provide the care rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. The records show that in March 2020, the enrollee was advised that follow-up visits with an OON provider were no longer accepted by the Plan. Therefore, we decided that the Plan does not have to pay for an office visit (99215) provided on October 14, 2020, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided
July 31, 2020 to August 29, 2020.
You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services received are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications
and insulin. The enrollee had stable vital signs. The enrollee used oxygen via nasal cannula. The enrollee was
monitored after an episode of hypoglycemia. The enrollee was independent with functional mobility including
walking to 100 feet. The documentation does not support that the enrollee required skilled nursing services or
skilled therapy services on a daily basis for the dates of service in question. Therefore, the enrollee did not meet
criteria for the services rendered.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided July 31, 2020 to August 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of your condition. Our physician reviewer found you have had prior therapy of 22 outpatient visits and the
records do not demonstrate that the unique skills of a professional therapist are required to safely and
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or
by or under the supervision of a therapist. You have been instructed in and is compliant in a home exercise
program. The requested services are not part of a maintenance program, are the specialized skill, knowledge
and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your
current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve eight (8) additional physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (CPT code 90839) provided to the enrollee on March 16, 2021, by a non-Medicare provider.
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary, and the enrollee was unable to choose the provider that was able to perform the service. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 psychotherapy have not been met.
The Centers for Medicare & Medicaid Services (CMS) guidelines clearly states that Licensed Professional
Counselors are not eligible to participate in Medicare. The Health Plan follows Medicare guidelines and the
claims denied correctly as an excluded non-covered service and no payment can be issued. Therefore, we
decided that the Plan does not have to pay for the psychotherapy (CPT code 90839) provided to the enrollee on
March 16, 2021, by a non-Medicare provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of the anterior segment aqueous drainage device provided on October 28, 2020, billed with code 0376T.
You asked the Plan to pay for the services as billed. You say that this is payable. The Plan denied your request. The Plan says this is not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 0376T is [CPT Codebook definition]. 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 as billed. Our reviewer says that the documentation does not support that code 0376T should be reported with 0191T.
Our reviewer found After reviewing Medicare guidelines and Corcoran Consulting Group specializing in coding an reimbursement issue for ophthalmology and optometry practices, for billing CPT 0376T in addition to CPT 0191T, coverage is determined by Medicare Administrative Contractor jurisdiction. Per the Centers for Medicare and Medicaid Services (CMS), "For most Medicare jurisdictions, only implantation of the first iStent at the time of cataract surgery is covered and paid; the surgeon's time and expertise to implant the second iStent is not separately paid even though it may be covered. Currently, only Wisconsin Physician Services (WPS) has a local coverage determination policy that covers implanting a second iStent." Documentation supports this procedure was performed in Indiana, therefore, this second stent is not required to be paid. 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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of the anterior segment aqueous drainage device provided on
October 28, 2020, billed with code 0376T.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics testing provided on June 19, 2020.
You asked the Plan to pay for the pharmacogenomics testing. You say that this testing is medically necessary to
allow for selection of the best drugs for the enrollee. The Plan denied your request. The Plan says this was not
billed correctly.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The documentation does not include a progress note showing that there is an established relationship between
the enrollee and the ordering physician. The ordering physician's specialty is physical medicine and
rehabilitation.
It is not clear that this type of specialist would be treating a specific condition for which extensive information about drug metabolism would be required. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services and radiofrequency ablation (RFA) rendered on April 30, 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 99152 is not supported and the RFA is experimental in nature.
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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to monitor the enrollee's level of consciousness and physiological status, first 15 minutes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that experimental services are not covered.
The file shows that the enrollee received RFA to the sacroiliac (SI) joint. These services are considered experimental/investigational in nature and are therefore not covered.
Therefore, we decided that the Plan does not have to pay for the moderate sedation services and radiofrequency ablation (RFA) rendered on April 30, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve endovenous ablation therapy of a varicose vein.
You asked the Plan to pre-approve the endovenous ablation procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that there was documented evidence of a thrombus (blood clot) of the left small saphenous vein of the lower leg.
The Plan follows Medicare rules. Medicare rules say that ERFA treatment of varicose veins is covered when medically necessary based on the criteria listed 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 the endovenous ablation procedure. Our reviewer says that the documentation supports that this treatment is medically necessary. Our physician reviewer found the criteria for this treatment are met because there is no aneurysm in the targeted segment of vein, the maximum diameter of the vein is within the required range, there is no clear thrombus or tortuosity, and there are no significant signs of peripheral artery disease.
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 endovenous ablation procedure have been met. Therefore, we decided that the Plan has to pre-approve endovenous ablation therapy of a varicose vein.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient radiological procedure
(71260) provided on August 27, 2020.
You asked the Plan to waive the copayment for an outpatient radiological procedure. You say that you should
not be charged as you met your maximum out of pocket costs in June. The Plan denied your request. The Plan
says the copayment applied correctly as you had not met your maximum out of pocket at the time of service.
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 $150
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $150 copayment for outpatient radiological procedure. The record shows that you did not meet your maximum out of pocket costs at the time of service. 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 outpatient radiological procedure (71260) provided on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services provided on
April 29, 2021.
You asked the Plan to waive the copayment for the surgical services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received surgical services on April 29, 2021. You were asked to pay a $350 copayment for the surgical services.
Your 2021 EOC states that enrollees must pay a $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 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 surgical services provided on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic digital breast tomosynthesis (77062), a dual-energy x-ray absorptiometry (DXA) and a diagnostic mammography (77066) provided on
June 3, 2021.
You asked the Plan to waive the copayment for diagnostic radiology services. You say that since you are a cancer patient, the copayment should be waived. The Plan denied your request. The Plan says the copayment 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 a $45 copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $45 copayment for diagnostic radiology services. The EOC confirms that $45 is the required copayment for these services. Diagnostic radiology services fall 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 a diagnostic digital breast tomosynthesis (77062), a dual-energy x-ray absorptiometry (DXA) and a diagnostic mammography (77066) provided on June 3, 2021.