Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded as 99140 provided on April 24, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim is always bundled into payment for other services not specified.
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 99140 is anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99140 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that this is a bundled service. This code is a bundled service to the primary code billed (00790). This means that this code is not separately payable. 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 services coded as 99140 provided on April 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 beneficiary is an 83-year-old female with Parkinson's disease and encephalopathy. In this case, there are no identifiable skilled nursing service needs no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vehicle arm handles (E1399) for your car.
You asked the Plan to pre-approve vehicle arm handles. You say that the car handles would allow you to get around better and would improve your mental condition. The Plan denied your request. The Plan says car handles are not covered as they are not for use in the home, do not serve a medical purpose and are not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the vehicle arm handles (E1399) for your car.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing (CPT code 81479) provided to the enrollee on February 25, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says screening services without a valid medical diagnosis related to the health of the patient are not a benefit.
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, the testing, is being 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 molecular genetic screening testing (CPT code 81479) provided to the enrollee on February 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
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. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you had a physician follow up visit on September 2, 2021 and the note states you are doing well. An order for service bathing was written on September 15, 2021. The records do not document that you have an skilled nursing needs or skilled therapy needs. As such, home health aide services are 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 home health aide services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the low dose computed tomography (LDCT) scan for lung cancer screening coded as 71271 provided March 12, 2021.
You asked the Plan to pay for the LDCT scan. You say that please review the attached medical records to show that the service provided to the enrollee was medically necessary and reprocess. The Plan denied your request. The Plan says that there is a more appropriate code to describe the services provided.
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 71271 is computed tomography, thorax, low dose for lung cancer screening, without contrast material(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 LDCT scan. Our reviewer says that the medical records provided meets the criteria for the service billed. Our reviewer found the enrollee received services on March 12, 2021 for Current Procedural Terminology (CPT) 71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s). Documentation submitted was reviewed and does meet criteria. Per Medicare on January 31, 2021 a change to report a Low dose lung cancer screening has changed to CPT 71271. "This is a reminder that HCPCS code G0297 (Low dose CT scan (LDCT) for Lung Cancer Screening) is no longer a valid code and will no longer be accepted by the HETS 270/271 Medicare eligibility system after January 31, 2021. Submitters that were previously using the G0297 code must transition to code 71271". Therefore, there is not a more appropriate code to report for this service. You can find this rule at CMS.gov Medicare HETS 270/271 - Reminder - HETS HCPCS Code Change Effective January 31, 2021. 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 diagnostic service have been met. Therefore, we decided that the Plan has to pay for the low dose computed tomography (LDCT) scan for lung cancer screening coded as 71271 provided March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy coded as 31624 provided July 6, 2020.
You asked the Plan to pay for the bronchoscopy. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the medical records do not corroborate the code 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 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed.
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 bronchoscopy. Our reviewer says that the criteria does not support the code as it is billed. Our reviewer found the documentation submitted does not include a bronchoscopy procedure. Of note, there is a note dated July 7, 2020 stating "Bronchoscopy performed this morning after CXR showed left lung mucous plugging"; however, an actual procedure was not found in documentation submitted. 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 bronchoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the bronchoscopy coded as 31624 provided July 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the medical records provided support the need for care in a SNF. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April
26, 2021, through May 2, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to be
responsible for your copayment because you would not have been in there that many days if the doctor did not
nip your artery. 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 shows that you were admitted on August 26, 2021, and discharged on May 2, 2021. You
were asked to pay a $325 copayment per day from August 26, 2021, through May 1, 2021, days 1-6 of your
inpatient hospital care. You were discharged on May 2, 2021, and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-6. 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 care provided from April 26, 2021, through May 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on April 5, 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 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 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 computed tomography (CT) scan of the head/brain rendered on April 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services coded as 99284 provided on February 20, 2021.
You asked the Plan to pay for the emergency room services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the coverage criteria have not been met for this specific code.
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 99284 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate 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 require urgent evaluation by the physician, or other qualified health care professionals but do not
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 emergency room services. Our reviewer says that the medical records do not support the services as billed. Our reviewer found that the reviewed documentation indicates that the medical record did not support the billed code 99284, Specifically, the presenting problem(s) were not of high severity, and did not pose an immediate significant threat to life or physiologic function. 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 emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services coded as 99284 provided on February 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services provided on April 26, 2021, in a Federally-Qualified Health Center (FQHC), billed with codes G2025 and 90834.
You asked the Plan to pay for the FQHC mental telehealth services. You say that this was a medically necessary service and should be paid. The Plan denied your request. The Plan says that services of psychologists are only payable when they have documented a consultation with the enrollee's primary care physician. There is no documentation of this in the medical record.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided an applicable denial rationale for the services at issue. The rule regarding a required consultation applies to services rendered and billed by a clinical psychologist or clinical social worker. The services at issue in this case, however, were rendered and billed by a FQHC. We find that the documentation supports that these services were correctly reported on the FQHC claim, and medical records support that the services were rendered. There is no argument provided to support non-payment for the FQHC services. Therefore, we decided that the Plan has to pay for the psychotherapy services provided on April 26, 2021, in a Federally-Qualified Health Center (FQHC), billed with codes G2025 and 90834.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on April 27, 2021, billed with code G0453.

You asked the Plan to pay for the IONM services. You say that this should be covered. The Plan denied your request. The Plan says this code was billed with E05.00 which is not a covered diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that IONM for thyroidectomy procedures are to be reported with diagnosis code E07.9. 

The file does not support that this diagnosis code was used on this claim. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on April 27, 2021, billed with code G0453.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketorolac solution, .5%.

You asked the Plan to pre-approve Ketorolac solution. You say that this is a surgical eye drop for cataract surgery. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ketorolac solution, .5%.

Benefits for Ketorolac solution may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the morphometric tumor immunohistochemistry analysis (88361) provided as part of the WATS-3D testing provided on March 30, 2021.
You asked the Plan to pay for the morphometric tumor immunohistochemistry analysis. You say that this is medically necessary to allow physicians to monitor a Barrett's esophagus patient for neoplasia. The Plan denied your request. The Plan says that this code was not billed with one of the allowed diagnosis codes per the Plan's policy.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a valid denial rationale based on Medicare guidelines. The documentation indicates that this testing was billed with 5 codes. Codes 43239, 88104, 88305, and 88312 were paid. The denial reason given for 88361 is that it was not reported with a diagnosis code that is listed in the Plan's internal policy criteria. Though Plans may use internal criteria in their billing and coding systems, Maximus is not able to use an internal plan policy as a basis for supporting a denial. We have not found any Medicare regulation which restricts coverage of code 88361 to only certain diagnoses. As such, we find this denial of payment is not supported. Therefore, we decided that the Plan has to pay for the morphometric tumor immunohistochemistry analysis (88361) provided as part of the WATS-3D testing provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on February 23, 2021.

You asked the Plan to pay for the fixed partial denture sectioning. You say that you expected your insurance to cover this work because your dentist said it was needed. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed
partial denture sectioning (D9120) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3421), retrograde filling (D3430), and biologic materials to aid in soft and osseous tissue regeneration (D3431) provided on April 14, 2021.

You asked the Plan to pay for the apicoectomy, retrograde filling, and biologic materials. The Plan denied your request. The Plan says these services are not covered by the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the apicoectomy (D3421), retrograde filling (D3430), and biologic materials to aid in soft and osseous tissue regeneration (D3431) provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on December 11, 2020.
You asked the Plan to pay for the endodontic therapy. You say that you believe it was an oversite not to have had endodontics included in your dental coverage for 2020. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on December 11, 2020.