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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided
May 21, 2021 to June 19, 2021.
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 rendered 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 the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee has colitis. The enrollee had
stable vital signs. The enrollee received oral medications. The documentation shows that the enrollee required
contact guard assistance with functional mobility. The enrollee did not require skilled nursing services or
skilled therapy services on a daily basis for the dates in question.
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 May 21, 2021 to June 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic testing provided on April 27, 2021, described by codes 81406 and 81479.
You asked the Plan to pay for the genetic testing. You say that this is medically necessary as ordered by the treating physician. The Plan denied your request. The Plan says that some of the codes were paid, but two remained denied since this is a noncovered testing panel.
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 a reasonable denial rationale pertaining specifically to the two line items of the billed panel. Five of the seven line items were approved on appeal. The Plan attempts to use a rationale stating that the other two codes cannot be paid because they are a noncovered genetic cardiovascular risk assessment. This is contradicted by the payment being made for all the other codes, which all together represent this panel. No cogent rationale was provided to support paying only certain line items and denying these two. In addition, this was ordered by a network provider, and there is no rule cited with clearly would indicate this as noncovered testing. As such, we find this denial is not substantiated. Therefore, we decided that the Plan has to pay for the genetic testing provided on April 27, 2021, described by codes 81406 and 81479.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular electrical stimulator (NMES) provided on June 14, 2021.
You asked the Plan to pay for a NMES. 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 follows Medicare rules. Medicare rules say that coverage for NMES/FES for walking will be covered in SCI patients when specific criteria are met. 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 a NMES. Our reviewer says that the services are not medically necessary. Our physician reviewer found the items/services at issue in this case medically reasonable and necessary. The enrollee does not meet all of the coverage criteria outlined in the NCD. 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 NMES have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular electrical stimulator (NMES) provided on June 14, 2021.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the testing described by codes 87150, 87338, 83520 x5, 82656, 83631,
82274, 87177, 87209, 82705-XU, and 89055. We decided that the Plan does not have to pay for the testing
described by code 87798.
You asked the Plan to pay for the testing described by codes 87150, 87338, 83520 x5, 82656, 83631, 82274,
87177, 87209, 82705-XU, and 89055. You say that the claim was correctly billed for medically necessary
testing. The Plan says that code 87798 is not payable since it was billed on the same date as 87150, and no
modifier was used.
We decided that the Plan has to pay for the testing described by codes 87150, 87338, 83520 x5, 82656,
83631, 82274, 87177, 87209, 82705-XU, and 89055.
The Plan follows 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 provide no reason to support the denial of payment for these codes. The claim denial indicates only
that information was not received. Without a valid reason that these codes are not payable, we find that the
denial is not supported. Therefore, we decided that the Plan has to pay for the testing described by codes
87150, 87338, 83520 x5, 82656, 83631, 82274, 87177, 87209, 82705-XU, and 89055.
We also decided that the Plan does not have to pay for the testing described by code 87798.
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only
the Column 1 code is payable unless a clinically appropriate modifier is used.
Code 87798 is a Column 2 code in relation to 87150, which was also billed on this claim. No clinically
appropriate modifier was used to justify bypassing this edit. Therefore, we decided that the Plan does not have
to pay for the testing described by code 87798.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 2, 2021, billed with
codes 81291, 71401, 81403, 81404, 81405, and 81406.
You asked the Plan to pay for the genetic testing as billed. You say that these are separately payable from code
81439. The NCCI edits can be overridden which is why modifier -XS was reported. The Plan denied your
request. The Plan says these codes are not separately 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, we have confirmed that the billed codes are column II codes to column I code 81439. Although
modifier -XS was reported for these line items, the remarks section of the claim do not specify the individual
genes being described by these procedure codes. Without this information, it cannot be determined that they
represent genes not included in code 81439. 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 genetic testing provided on
February 2, 2021, billed with codes 81291, 71401, 81403, 81404, 81405, and 81406.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health skilled nursing services. 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 home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health skilled nursing services.
Our reviewer says that the documentation does not support that the requested services are medically reasonable
or necessary. Our physician reviewer found the enrollee has worsening internal tremor, worse walking, and
more stiffness. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care,
new ostomy). As such, the requested, ongoing, home health skilled nursing services are not medically
necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99215) provided to the enrollee on November 12, 2020, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 office visit (CPT code 99215) provided to the enrollee on November 12, 2020, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services received on February 3, 2021
and February 4, 2021.
You asked the Plan to pay for the physical therapy services. You say that you did not receive physical therapy
services on this date of service. The Plan denied your request. The Plan says the services have been processed
correctly per your plan benefits.
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 asked our physician 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 physical therapy services. Our reviewer says that the
documentation does support that you had a physical therapy evaluation and treatment on the date of service of
February 4, 2021. Our reviewer found the documentation includes an order for physical therapy and treatment
that was submitted on February 3, 2021 at 15:01:00 CST. The subjective portion of the therapy note on
February 4, 2021 states that you are agreeable with physical therapy. The documentation shows that you denied
joint pain at rest or walking. You have pain with exercises, especially sitting. You reported familiarity and had
hip surgery in the past. The objective portion of the exam states you were independent /stand-by assistance for
supine to sit, sit to stand with rolling walker and ambulated 200 feet with rolling walker with cues. You
performed therapeutic exercises.
The physical therapist stated a second visit was not indicated prior to discharge and recommended home with
contact guard assist and home health physical therapy. Therefore, the documentation indicates that you had a
physical therapy evaluation and treatment on this date of service in question.
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 physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pay for the physical therapy services received on February 3, 2021 and February 4, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from
March 1, 2020, through March 24, 2020, billed with codes KDKE1 for 10 days and KDGC0 for 13 days.
You asked the Plan to pay for the SNF services as billed. You say that the records support the billing and the information documented on the two assessments. The Plan denied your request. The Plan says that the documentation provided does not support coding of all Section GG payment items which results in a reduction of the therapy and nursing components of the score.
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's denial rationale is based on its claim that the usual functional abilities documented on the Interim Payment Assessment (IPA) are not supported. However, we find that this rationale is not sufficient specific to justify reduction/adjustment of the coding for these items. The Plan has not cited any specific functional ability that is felt to be incorrect. The lookback period for the IPA is the date of the assessment plus the two preceding days. Without a specific discrepancy being cited to indicate that these data are invalid for this period, we find that the Plan's denial is not substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from March 1, 2020, through
March 24, 2020, billed with codes KDKE1 for 10 days and KDGC0 for 13 days.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for moderate sedation services (G0500)
provided on July 31, 2020.
You asked the Plan to waive the coinsurance for moderate sedation services. You say that have had this
procedure done once a year for the past three years and never had a coinsurance before. You also say that you
had a colonoscopy and an endoscopy this time and you are unsure if this is the reason for the cost share. The
Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for moderate sedation services. The allowed amount of the claim is $737.80, resulting in a coinsurance obligation of $147.56. The EOC confirms that 20% is the required coinsurance for this service. Moderate sedation services fall within the Medicare Part B prescription drugs 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 coinsurance for moderate sedation services (G0500) provided on July 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee required modified independent to independent level with functional mobility including gait to 200 feet with a rolling walker. The documentation does not support that the enrollee requires skilled nursing services. The documentation does not support that the enrollee requires skilled nursing or therapy services on a daily basis. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services coded 88108 provided on
February 1, 2021.
You asked the Plan to pay for the cytopathology 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.
In this case, the CPT Code Manual definition of code 88108 is cytopathology, concentration technique, smears
and interpretation (eg, Saccomanno technique).
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 cytopathology services. Our reviewer says that the
documentation does not support the services billed. Our reviewer found the documentation supports that the
services were provided while the enrollee was inpatient status. Laboratory tests performed for hospital
inpatients are considered part of the DRG payment and would not be considered separately. Therefore, the
services are not payable as billed.
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 cytopathology services have not been met. Therefore, we decided that the
Plan does not have to pay for the cytopathology services coded 88108 provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve image guided radiation therapy (IGRT).
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 medically necessary. Our physician reviewer found IGRT is a means to improve set-up accuracy. Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Given the need to minimize set-up uncertainty in the setting of prior radiation, there is plausible need for IGRT for this enrollee. The use of IGRT is within the accepted standards of medical practice in the setting or re-irradiation. 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 been met. Therefore, we decided that the Plan has to pre-approve image guided radiation therapy (IGRT).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a home ventilator. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network. The Plan says there are equally qualified in-network suppliers available that can provide a non-invasive home ventilator.
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 a home ventilator to be provided by an out-of-network (OON) provider.