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

We decided that the Plan does not have to pay for the laboratory services coded 81291, 81407, 81408, 81479, 81439, 81401, 81403, 81404, 81405, and 81406 provided on July 15, 2020.

You asked the Plan to pay for the laboratory 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. Providers must report services with the appropriate CPT code. Cardiovascular risk assessment panels are only covered for certain indications.

We find that CPT codes 81291, 81407, 81408, 81479, 81439, 81401, 81403, 81404, 81405, and 81406 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Therefore, codes Code 81401, 81403, 81404, 81405, and 81406 are not supported by the documentation. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. This means procedure codes 81291, 81407, 81408, 81479, and 81439 are not covered. 

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81291, 81407, 81408, 81479, 81439, 81401, 81403, 81404, 81405, and 81406 provided on July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested treatment is experimental/investigational.
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 a Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the requested procedure is considered experimental/investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that you don't want to get sent to a skilled nursing facility (SNF), as you got coronavirus last time you were there. The Plan denied your request. The Plan says the services can be safely received in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable with debility after surgery for osteomyelitis of the left foot. There is no medical complexity. You do not require physician supervision three times a week for the ongoing management of any active or acute exacerbations of chronic medical conditions.
There are no documented rehabilitation nursing needs. You are functionally at a high level. The documentation does not support the need for a therapy program consisting of at least three hours of therapy per day, at least five days a week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Your needs can be addressed at a lower intensity and alternate setting such as in an SNF. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of a spinal neurostimulator pulse
generator or receiver (63685) rendered by the OON provider on March 19, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without an authorization or a referral from the enrollee's PCP.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the insertion or replacement of a spinal neurostimulator pulse generator or receiver
(63685) rendered by the OON provider on March 19, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for therapy services provided from July 31, 2020, through August 30, 2020.
You asked the Plan to pay for the therapy services. You say that codes 97530 and 97140 is a comprehensive/component code pairing so modifier 59 is appropriately placed. You say that the therapy services were deemed necessary by the supervising physician and were in compliance with Medicare guidelines. The Plan denied your request. The Plan says that the denial is upheld until a corrected claim is received.
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 support its rationale that the modifiers are invalid based on any cited rule. The modifiers used are all applicable to outpatient therapy services. Without a valid justification, we find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for therapy services provided from July 31, 2020, through August 30, 2020.
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 plastic surgery services (14040) provided to the enrollee on September 20, 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 procedure code 14040 is not supported by the medical records submitted.
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 14040 is "adjacent tissue transfer or rearrangement of the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; for defect 10sq 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the operative report does not include enough detail to confirm the tissue remains connected to its origin with intact blood supply.
To cite the operative report, "An open reduction of the distal phalanx fracture was then performed. Following this, an incision was made proximally, and a volar advancement flap was created and advanced to fill the full-thickness soft tissue defect in the distal aspect of the right thumb." An adjacent tissue transfer cannot be confirmed. 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 plastic surgery services (14040) provided to the enrollee on September 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional sessions of occupational therapy.
You asked the Plan to pre-approve 14 additional sessions of occupational therapy. 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 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 14 additional sessions of occupational therapy.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided
there is no documentation why the additional ten occupational therapy visits approved by the plan are not
adequate to treat the enrollee's condition and transition her to a home exercise program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 14 additional sessions of occupational therapy have not been met. Therefore, we
decided that the Plan does not have to pre-approve 14 additional sessions of occupational therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from March 2, 2021 to March 31, 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 were 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization for flap reconstruction of thigh ulcer and complex closure of a shoulder wound. She received oral medications and had stable vital signs. There is no documentation that she received skilled therapy services. She had no skilled nursing or skilled therapy needs for the dates in question. She did not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from March 2, 2021 to March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), bitewing radiographic images (D0274), and fillings (D2932, D2332) provided from March 10, 2021, through April 27, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, bitewing radiographic images and fillings. You say that the services should be covered. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, bitewing radiographic images and fillings have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), bitewing radiographic images (D0274), and fillings (D2932, D2332) provided from March 10, 2021, through April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on December 9, 2020.
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. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 80307 and G0483 provided on December 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed Tomography Cerebral Perfusion Analysis (CTP) (0042T) provided on April 7, 2021.
You asked the Plan to pay for code 0042T. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records to verify if the services provided met Medicare criteria for payment. Therefore, we decided that the Plan does not have to pay for the Computed Tomography Cerebral Perfusion Analysis (CTP) (0042T) provided on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 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 29826 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 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure). We find that CPT code 29826 is not supported in the medical record. Specifically, there is no documentation of surgical shoulder arthroscopy with decompression of subacromial space with a partial acromioplasty.
Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on December 21, 2020 by an out-of-network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
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 outpatient mental health services provided on December 21, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation of a chest x-ray provided on February 7, 2021.
You asked the Plan to pay for the chest x-ray interpretation. You say that this should not have been denied as duplicate. The x-ray was done at one emergency room, after which the patient was transferred to a different facility. Another chest x-ray was done there. The Plan denied your request. The Plan says that this claim was denied as duplicate as there was another claim paid from the same billing provider for this same service. Medicare cannot pay duplicate claims for the same service.
The Plan must follow Medicare rules. Medicare rules say that claims that appears to be exact duplicates are denied, but the denial is appealable. In this case, further review clearly shows that the claim at issue is not a duplicate. The rendering provider on each claim is different, and the services were provided at different facilities. There is nothing to suggest that payment for the chest x-ray was already made on the "duplicate" claim. Therefore, we decided that the Plan has to pay for the interpretation of a chest x-ray provided on February 7, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from March 7, 2021, through March 22, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says that dates of service February 21, 2021, through March 6, 2021 are overturned, not to exceed the member's 100-day SNF benefit. The Plan previously approved SNF level benefits from January 26, 2021, through February 20, 2021, May 2, 2021, through June 12, 2021 and June 23, 2021, through July 10, 2021. The member's 100-day SNF benefit exhausted on March 6, 2021. Therefore, dates of service March 7, 2021, through March 22, 2021 are upheld due to exhaustion of benefits.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 26, 2021, through March 6, 2021.The Plan has covered 100 days of SNF care. 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for SNF services provided from March 7, 2021, through March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office visit to be provided by an out-of-network (OON) provider.