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

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 19, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says overlapping services are considered mutually exclusive.
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 70450 is computed tomography, head or brain; without contrast material. We find that CPT code 70450 was billed with code 70496, which was paid for by the Plan. The paid code, 70496, is the most comprehensive code that describes the services provided.
Furthermore, the records provided do not show that 3 tests were provided on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 19, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 1, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathtub wall rail and bathtub chair.
You asked the Plan to pre-approve the items. You say that both of these items are necessary for your health. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a bathtub wall rail and bathtub chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy provided from May 7, 2021, through May 14, 2021.
You asked the Plan to pay for the electric stimulation therapy. You say that you went to physical therapy until you hit a plateau and continued to do the recommended exercises at home. You say that you were told they sent the proper paperwork, and you are appealing the denied claims. The Plan denied your request. The Plan says this code is not valid. The Plan also says that you are not responsible for the denied procedure on the claims.
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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy provided from May 7, 2021, through May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from April 15, 2021, to May 21, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit was exceeded.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation shows that the benefit limit of 25 visits per year had been reached prior to the service in question. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from April 15, 2021, to May 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 2, 2020.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   We looked at 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. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete bilateral noninvasive physiologic studies of
upper or lower extremity arteries, 3 or more levels (93923).
You asked the Plan to pre-approve noninvasive physiologic studies. You say that you are appealing regarding
the medical necessity for arterial doppler to continue to evaluate surrogate for graft patency for abdominal
aortic aneurysm repair that was performed 6/26/2016. The Plan denied your request. The Plan says arterial
doppler of lower extremities is not reasonable or medically necessary and does not meet the LCD criteria.
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 noninvasive physiologic studies. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not support the medical necessity of surveillance
multilevel arterial Doppler studies. While yearly surveillance of open abdominal aortic aneurysm repair with
arterial Doppler studies is reasonable, this can be obtained with yearly single level studies, reserving multilevel
studies if the ABIs are abnormal/change or clinical findings substantially change. Agree with health plan
determination; recommend resubmitting with request for approval of a single level arterial Doppler study, also
known as an ABI.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of noninvasive physiologic studies have not been met. Therefore, we decided that
the Plan does not have to pre-approve complete bilateral noninvasive physiologic studies of upper or lower
extremity arteries, 3 or more levels (93923)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a three level facet joint injection for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a unique circumstance to allow for a three level procedure.

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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, there is no documentation provided to support a unique circumstance for a three-level procedure. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a three level facet joint injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on July 12, 2021.
You asked the Plan to pay for the SelectMDx testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 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 SelectMDx testing 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 SelectMDx testing provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on March 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the bitewing x-rays and prophylaxis. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that non-emergency services provided by an OON provider are not available with 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the itewing x-rays (D0274) and prophylaxis (D1110) provided on March 31, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided February 22, 2021.

You asked the Plan to pay for the radiology service. You say that the enrollee had multiple claims on this date of service. You have attached the report to support the level of service. Please reconsider for processing. The Plan denied your request. The Plan says this is a duplicate claim that has already been considered for payment.

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 71045 is radiologic examination, chest. 

We find that CPT code 71045 is not supported in the medical record. Specifically, the records show that the plan had paid 71045-26 and 71045-26-77x2 were paid for the date of service. Based on this information, we decided that Medicare rules for coverage of the radiology service have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a semi-electric hospital bed.  You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the required documentation was not received.  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 the bed. Our reviewer says that the requested bed is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for you.  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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the transrectal ultrasound you had on July 21, 2021.

You asked the Plan to reduce the copayment for the ultrasound. You say that you think the ultrasound should only have a $30 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $155 copayment for diagnostic radiological services except for x-rays. 

You have been asked to pay a $155 copayment for the ultrasound. This copayment applies to all types of diagnostic radiological services except for x-rays. Ultrasounds fall into this 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 reduce the copayment for the transrectal ultrasound you had on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 29, 2021.

You asked the Plan to waive the copayment for arthrocentesis. You say that you feel that the charges are too high for the procedure you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received arthrocentesis at an outpatient hospital facility on June 29, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment.

You have been asked to pay a $275 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 5, 2021.
You asked the Plan to pay for the targeted genomic sequence analysis panel. 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 code 0242U is 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 on an On Campus-Outpatient Hospital, place of service 22. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound provided on July 13, 2021.

You asked the Plan to reduce the copayment for the ultrasound. You say that you were told at the time of service that your copayment was $7. You say you want the Plan to pay the additional amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

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 $110 copayment for radiological diagnostic services, including ultrasounds. 

You have been asked to pay $79.88, which is less than the $110 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the ultrasound provided on July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is medically necessary for
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met.
There is no documentation that the complexity of the enrollee's medical conditions requires physician
oversight; therapy services can be provided in a lower level of care.
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 based on the available records, the enrollee is medically stable. She does not require a
physical medicine and rehabilitation physician's supervision three times a week in an IRF. She has no acute
rehab nursing needs. Based upon the enrollee's current level of function, she does not require intensive
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary
approach to daily therapy. She will not make a significant progress in a reasonable and predicted period of time
(7-10 days) in an IRF. IRF admission is not medically necessary. While the enrollee may benefit from physical,
speech and occupational therapies, her rehab needs can be safely met in an alternate and low intensity setting
such as in a skilled nursing facility.
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95909, 95886) provided on March 15,2 021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.

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 95909 is "Nerve conduction studies; 5-6 studies." The CPT code Manual definition of code 95886 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)." 

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 use of codes 95909 and 95886 is not supported by the records provided. Our reviewer found that for CPT 95909, the technical report does not include documentation showing nerve conduction studies were performed, and therefore cannot be verified. The technical report documents and Lower EMG; Train-of-Four; and Pedical Testing (which is not considered, nerve conduction studies which measure amplitude; latency and conduction velocity). For CPT 95886, the technical report does not include documentation of needle electromyography with nerve conduction studies; as nerve conduction studies are not documented in the technical report. When reporting CPT codes, all criteria within the code description must be documented. Therefore, this procedure would not be covered. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95909, 95886) provided on March 15,2 021.