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

We decided that the Plan does not have to pre-approve a Vertiflex superion device.
You asked the Plan to pre-approve a Vertiflex superion device. 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 superion device. 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 superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the eyewear provided on January 21, 2021.
You asked the Plan to pay more for the eyewear. You say that you were given the incorrect information about the price of your glasses. You say that you paid what they asked for at the time of service and should not be responsible for the additional amount. The Plan denied your request. The Plan says the Medicare-covered standard frames and lenses for cataracts up to the Medicare allowed amount are covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a certain cost depending on the brand of frames and where the glasses are purchased. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Specifically, the Plan benefit amount for glasses has been reached. Therefore, we decided that the Plan does not have to pay more for the eyewear provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4kScore testing provided on December 28, 2020.
You asked the Plan to pay for the 4Kscore testing. You say that you would like reconsideration because this testing is a safe and effective method to aid in evaluating the need for a prostate biopsy. The Plan denied your request. The Plan says this testing is never covered.
The Plan follows Medicare rules. Medicare rules say that any test that does not contain a DRE is considered not 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 pay for the 4Kscore testing. Our reviewer says that the documentation submitted does not support the 4Kscore test algorithm. Our physician reviewer found the documentation does not include evidence of a DRE.
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 4Kscore testing have not been met. Therefore, we decided that the Plan does not have to pay for the 4kScore testing provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external counter pulsation therapy and related services.

You asked the Plan to pre-approve the external counterpulsation therapy and related services. You say that this requested procedure should be considered as potentially beneficial for the enrollee's long-stage coronavirus infection. The Plan denied your request. The Plan says the indication that this procedure is requested for is not a covered indication.

The Plan must follow Medicare rules. Medicare rules say that all other indications not listed in the Medicare rules for ECP therapy remain non-covered. 

We looked at the file and Medicare rules. In this case, you have requested ECP for coronavirus infection which is not medically-accepted indication. Based on this information, we decided that Medicare rules for coverage of the external counterpulsation therapy and related services have not been met. Therefore, we decided that the Plan does not have to pre-approve the external counter pulsation therapy and related services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation services (99217) provided May 30, 2021.
You asked the Plan to pay for the observation services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99217 is not supported in the medical record. Specifically, payment for a subsequent
observation care code is for all the care rendered by the treating physician on the day other than the initial or
discharge date. All other physicians who furnish consultations or additional evaluations or services while the
patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.
Based on this information, we decided that Medicare rules for coverage of the observation services have not
been met. Therefore, we decided that the Plan does not have to pay for observation services (99217) provided
May 30, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on September 21, 2020, to September 22, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the full admission, from September 15, 2020, to September 22, 2020, was medically necessary. The Plan denied your request. The Plan says that the enrollee's delay in discharge was not medically necessary for treatment as an extended acute inpatient stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on September 21, 2020, to September 22, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 9, 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 billed incorrectly.
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 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for Infrared therapy provided on March 12, 2021.
You asked the Plan to pay for Infrared therapy. You say that the patient was seen for acupuncture services and according to the benefit verification, acupuncture is a covered benefit under the patient's health Plan. The Plan denied your request. The Plan says Infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of INFRARED THERAPY devices and any related accessories is not reasonable and necessary.
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of Infrared theapy devices and any related accessories is not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of Infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for Infrared therapy provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter guidance rendered on December 2, 2020.

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 C1887 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 C1887 is catheter, guiding (may include infusion/perfusion capability).

We find that CPT code C1887 is not supported in the medical record. Specifically, there is no documentation to support 12 units of catheter guiding. 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 catheter guidance rendered on December 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on April 13, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71110 (bilateral rib xray,
three views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I
code 71110. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore,
we decided that the Plan does not have to pay for the chest x-ray rendered on April 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on January 18 to March 4, 2021.
You asked the Plan to pay for psychotherapy services. You say that the requested services were a necessity for the enrollee's care. 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 clinical social worker 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 (90834) provided on January 18 to March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76140) provided on May 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code 76140 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 (76140) provided on May 30, 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 based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case after October 17, 2021. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services from outside the operating room for more than one patient provided on April 8, 2021, billed with code 95941.
You asked the Plan to pay for the IONM billed with code 95941. You say that these codes should be paid. The Plan denied your request. The Plan says payment can only be made for 95940. 95941 is a noncovered code per Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that payment is not allowed for IONM services when more than one patient is being monitoring. As such, code 95941 is not covered. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services from outside the operating room for more than one patient provided on April 8, 2021, billed with code 95941.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cardioversion procedure you had at a non-preferred outpatient hospital facility on June 1, 2021.
You asked the Plan to reduce the copayment for the cardioversion procedure. You say that you shouldn't be charged the non-preferred date because you were never notified that this facility was non-preferred. You said that this is the only hospital close to you. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that your provider directory lists the facilities that are preferred. The facility where you had this procedure is non-preferred.
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 $440 copayment for outpatient procedures at a non-preferred facility.
You have been asked to pay a $440 copayment for the cardioversion procedure. We have confirmed in the Plan's online provider directory that the facility where you received these services is not a preferred facility. That is why the cardioversion procedure falls within the outpatient procedures at a non-preferred facility 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 cardioversion procedure you had at a non-preferred outpatient hospital facility on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on May 29, 2021, to May 31, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay was medically necessary. The Plan denied your request. The Plan says that the enrollee was well-appearing and in no distress upon admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on May 29, 2021, to May 31, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95955), neuromuscular junction testing (95937), nerve conduction studies (95908) and short-latency somatosensory evoked potential study (95927) provided on February 9, 2021.
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 neuromonitoring services. Our reviewer says that CPT code 95955 does not meet criteria for billing or reimbursement consideration.
Per the documentation an EEG was performed through procedure. This is the incorrect code to report for this procedure. Any baseline EEG performed would be included in the primary code. The technical report does not include documentation of Neuromuscular junction testing. If reporting this code for Train of Four, this would be the incorrect code to report, as Train of Four testing is included in the primary surgery.when coded correctly. CPT code 95937 does not meet criteria for billing or reimbursement consideration. Our reviewer found CPT code 95908 does not meet criteria for billing or reimbursement consideration. The technical report does not support nerve conduction testing, which would measurements of amplitude, latency and conduction velocity. The documentation supports Pedicle screw stimulation which would not be reported using this code. CPT 95927 does not meet criteria for billing or reimbursement consideration. The technical report does not document this procedure. 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 neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95955), neuromuscular junction testing (95937), nerve conduction studies (95908) and short-latency somatosensory evoked potential study (95927) provided on February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the omentectomy rendered on May 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 49255 (omentectomy) and 49560 (repair of initial
incisional or ventral hernia; reducible). Code 49255 is a column II code with a modifier indicator of 1 when
billed with column I code 49560. Code 49255 was not billed with an appropriate modifier to allow for separate
payment. Therefore, we decided that the Plan does not have to pay for the omentectomy rendered on May 24,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery provided on May 13, 2021, billed with code D4341.
You asked the Plan to pay for the osseous surgery. You say that this is listed as a covered service in your contract. The Plan denied your request. The Plan says the service performed per the billed code is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Deep cleaning is covered by the Plan; however, the services described by the code billed are not standard deep cleaning services.
These are more complex surgical services which are not covered per your contract. Therefore, we decided that the Plan does not have to pay for the osseous surgery provided on May 13, 2021, billed with code D4341.