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

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 18, 2021.  You asked the Plan to pay for the services. You say that the Plan denied your request. The Plan says the medical records do not contain documentation of definitive laboratory results for 22 or more drug classes.  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 the denied codes is:    Healthcare Common Procedure Coding System (HCPCS) G0483:  Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed  CPT 80307:  Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service  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 review indicates that the medical records do not contain documentation of definitive laboratory results for 22 or more drug classes, including metabolites to support the coding criteria for G0483 for the billed date of service May 18, 2021. Only 19 drug classes were counted per the laboratory results 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services provided on June 28, 2021.  You asked the Plan to pay for the critical care services. You say that the records support that care was provided to a critically ill patient. The Plan denied your request. The Plan says no time was documented in the critical care progress note.  The Plan must follow Medicare rules. Medicare rules say that payment for critical care services requires that the time spent provided care be documented in the progress note.          The progress note submitted for review does not indicate time spent. As such, the Medicare rules for payment of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (70450) provided on July 14, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra.  You asked the Plan to pre-approve Xiidra. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Xiidra.   Benefits for Xiidra 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: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on April 21, 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 covered.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on March 2, 2021 to March 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the nursing facility care. You say that the service rendered was medically necessary and critical to the enrollee's health and well-being. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being 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. 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 subsequent nursing facility care (99309) provided on March 2, 2021 to March 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex spacer.  You asked the Plan to pre-approve a Vertiflex spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy.  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 spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for the bone density scan (procedure code 77080) you had on June 12, 2021.  You asked the Plan to waive the coinsurance for the bone density scan. You say that you were supposed to have a bone density scan, not a DEXA scan.  You should not have to pay a copayment for this. The Plan denied your request. The Plan says that you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay no cost sharing for bone mass measurement services.   The Plan says you must pay 10% coinsurance for the bone density scan. We do not agree.  Medicare rules explicitly state that bone density tests coded as 77080 are considered preventive bone mass measurements for which there is no cost sharing. The Evidence of Coverage also states that there is no cost sharing for bone mass measurements. Therefore, we decided that the Plan has to waive the coinsurance for the bone density scan (procedure code 77080) you had on June 12, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 1, 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 testing is not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of interbody biomechanical device (22853-59) and an autograft (20936) provided on May 19, 2021.  You asked the Plan to pay for the insertion of interbody biomechanical device and an autograft. You say that this is supported in the records. The Plan denied your request. The Plan says these services cannot be paid as billed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The rules also say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  The medical records provided do not show that code 22853 billed with the -59 modifier is a distinct procedural service. Specifically, the records indicate that the procedures performed were performed in a single patient encounter and site. Code 20936 has a status indicator of B, meaning it is not separately payable. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of interbody biomechanical device (22853-59) and an autograft (20936) provided on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on March 16, 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 codes 17000, 17003, and 17110 are not supported.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 17000 is Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of premalignant lesions (e.g., actinic keratoses), first lesion. The definition of code 17003 is destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of premalignant lesions (e.g., actinic keratoses), second through 14 lesions, each (List separately in addition to code for first lesion). The definition of code 17110 is destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions, up to 14 lesions.  We find that CPT codes 17000, 17003, and 17110 are not supported in the medical record. Specifically, there is no documentation of destruction of premalignant lesions, first lesion, to support code 17000. Given that primary code 17000 is not supported, add-on code 17003 is also not supported. There is no documentation of destruction of premalignant lesions, up to 14 lesions, to support code 17110. 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 March 16, 2021.
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 does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial skilled nursing facility care (99305) provided on March 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the skilled nursing facility care. You say that the services provided are medically necessary in the skilled nursing facility during their convalescence. The enrollee has no choice which physician render services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being 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. 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 initial skilled nursing facility care (99305) provided on March 24, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from May 29, 2021, to June 3, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you live on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $315 copayment for each of the first seven days of an inpatient hospital stay.   You have been asked to pay a $1,575 copayment for five days of inpatient hospital care ($315 x 5 days = $1,575). 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 inpatient hospital admission and services provided from May 29, 2021, to June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 23, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for codes 27245 and 27506.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 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 these services. Our reviewer found the documentation provided does not include an operative report to support the billing of codes 27245 and CPT 27506. We looked at this coder'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 medical services provided to the enrollee on April 22, 2021 and billed under codes 27245 and 27506.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for annual nursing facility assessment visit (99318) provided on September 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the nursing facility services. You say that the treatment the enrollee received was medically necessary. You have attached medical records and is requesting review of the documents and grant the appeal for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being 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. 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 annual nursing facility assessment visit (99318) provided on September 1, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on May 22, 2021.  You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on May 22, 2021.