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

We decided that the Plan does not have to pay for the assembly and operation of pump services coded 99190 provided on February 25, 2020. 
 
You asked the Plan to pay for the assembly and operation of pump 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 included in the DRG payment to the facility. 
 
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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. 
 
We find that CPT code 99190 is not supported in the medical record. Specifically, this service was provided to the enrollee while inpatient in the hospital. Payment for this service is included in the Part A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump services coded 99190 provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (92015) provided February 24, 2020.
You asked the Plan to pay for the vision services. You say that you have been going to this doctor for 10 years
to check for diabetes problems with your eyes, plus pressure in your eyes for glaucoma and you also have
cataracts. The Plan denied your request. The Plan says the refraction services was not provided as part of a
routine eye exam. The plan verified that the refraction was performed for medical reasons, therefore is not
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 when rendered during a routine exam performed by a routine vision
care provider.
We looked at the file and the Plan's rules. Refraction services are covered when rendered during a routine exam
performed by a routine vision care provider. The plan has verified that the refraction services was not provided
as part of a routine eye exam. The refraction was performed for medical reasons, therefore is not covered.
Based on this information, we decided that the Plan's rules for coverage of the vision services have not been
met. Therefore, we decided that the Plan does not have to pay for the refraction services (92015) provided
February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services (97112, 96372, 97032, 97016) and injections (J3490, J3420, J3415, J3411) provided in a chiropractic office in January 7, 2020. 
 
You asked the Plan to pay for therapeutic services and injections. You say that these services should be covered. The Plan denied your request. The Plan says these services are not covered when provided in a chiropractic office. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic services (97112, 96372, 97032, 97016) and injections (J3490, J3420, J3415, J3411) provided in a chiropractic office in January 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit provided December 20, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the services were medically necessary.
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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the Emergency Care 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 an Emergency Room Visit provided December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis, and the shoulder-elbow-wrist-hand orthosis provided on January 17, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis (L3916), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. There are no medical records supporting medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916), and the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis, and the shoulder-elbow-wrist-hand orthosis provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the augmentation of facial bones, gum graft, therapeutic, prophylactic, or diagnostic injection, and anesthesia services provided on January 3, 2020. 
 
You asked the Plan to pay for the augmentation of facial bones, gum graft, therapeutic, prophylactic, or diagnostic injection, and anesthesia services. You say that your tooth was cracked and could not hold the cap. You also say that you were advised by the Plan that the services would be covered. The Plan denied your request. The Plan says these services are not covered. 
 
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. Therefore, we decided that the Plan does not have to pay for the augmentation of facial bones, gum graft, therapeutic, prophylactic, or diagnostic injection, and anesthesia services provided on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) provided on March 16, 2020.
You asked the Plan to pay for the bitewings. You say that you have not been to the dentist in over a year. You also say that the last time you were at the dentist was in 2017, and your limit has not been exceeded. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.
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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on March 2, 2020 and your bitewings benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on March 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiation treatments provided from January 23, 2020 to February 27, 2020.
You asked the Plan to waive the copayments for the radiation treatments. You say that had you been informed about the copayments you would have selected a different treatment. You say you should not be responsible for the copayments. 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 $50 copayment for each Medicare-covered radiation therapy service. You have been asked to pay a $50 copayment for each of the radiation treatments. The radiation treatments fall 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 waive the copayments for the radiation treatments provided from January 23, 2020 to February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted to an acute care hospital with respiratory failure. He was intubated and has been extubated twice. The enrollee suffered cardiac arrest while a PEG tube was being placed. He was intubated for a third time during this hospitalization. The enrollee is currently undergoing weaning trials. The enrollee is extremely deconditioned and is currently receiving physical and occupational therapy. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that 25 or more days of acute hospitalization are reasonably expected for the enrollee in this case. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 14, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is 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 drugspecific 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. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include a valid physician order/lab requisition form or medical records signed by the ordering physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on March 13, 2020. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you have never been billed for the injections before. You say that you were informed you wouldn't have a charge. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $378.01, which is 20% of the allowed amount for the aflibercept injection. The allowed amount is $1,890.06 (20% x $1,890.06 = $378.01). The aflibercept injection falls 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 the aflibercept injection provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable


 We decided that the Plan does not have to pay for the drug testing coded G0481 provided on January 6, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0481 is 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 drugspecific 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; 8-14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records completed and signed by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0481 provided on January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest (71270). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found there is no clinical rationale for a CT scan of the chest. The enrollee has not had a recent chest x-ray. The requested CT scan of the chest is not medically reasonable or necessary. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest (71270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hotel fees and cell phone fees provided on October 2, 2019 while in the Philippines.
You asked the Plan to pay for these services. You say that these services should be covered. The Plan denied your request. The Plan says that these are not Medicare covered benefits.
The Plan must follow Medicare rules. Medicare rules say that services received outside of the United States are not covered. We looked at the file and Medicare rules. These services are not considered emergency, urgently needed, or post-stabilization care. 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 hotel fees and cell phone fees provided on October 2, 2019 while in the Philippines.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 13, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthoses provided on December 26, 2019.
You asked the Plan to pay for the wrist hand orthoses (L3916). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthoses provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (CPT 99223) provided to the enrollee on November 12, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the CPT code billed is inappropriate/invalid for the place of treatment submitted on the claim, therefore payment is not allowed. 
 
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 99223 is "initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit." 
 
We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found billing CPT 99223 with a place of service 52 is inappropriate. 
 
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 hospital services (CPT 99223) provided to the enrollee on November 12, 2019.