Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's acute medical problems have left her at a functional status below her baseline. The Plan denied your request. The Plan says the enrollee does not require an intensive and coordinated interdisciplinary approach to rehab 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 physician reviewer found that the enrollee was admitted to the acute care hospital for acute respiratory failure, congestive heart failure, COPD exacerbation, pneumonia, and toxic megacolon with sepsis. Her medical conditions are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccine provided on January 14, 2021.
You asked the Plan to pay for the Shingrix vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a Shingrix vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Shingrix vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine provided on January 14, 2021.
Benefits for the Shingrix vaccine 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (CPT 97110) provided to the enrollee on August 29, 2020.
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 Current Procedural Terminology (CPT) code 97110 GP, CQ, KX (4 units) remains 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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 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 supported by the medical records. Our coding reviewer found the services were performed by a physical therapy assistant, which is considered technical, and a qualified healthcare professional.
There is a more appropriate Healthcare Common Procedural Coding System (HCPS) code to report for this service. 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 physical therapy (CPT 97110) provided to the enrollee on August 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cranial maxillofacial surgery (21299), head surgery (21499), and the office visit (99215) provided. Additionally, the Plan does not have to pay for the joint survey (77077) provided on September 28, 2020.

You asked the Plan to waive the coinsurance for the cranial maxillofacial surgery, head surgery, and the office visit. Additionally, you asked the Plan to pay for the joint survey. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request.

The Plan says the coinsurance has been applied correctly to the services provided. Additionally, CPT code 77077 is not payable as the service was billed incorrectly by the provider.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for out of network provider and professional services rendered at a specialist's office.

You have been asked to pay $231.53 ($1157.68 x 20% coinsurance) for the out of network professional services rendered at the specialist's office. 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. Additionally, we find that CPT code 77077 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77077 has a bilateral indicator of 0. This means that it is not appropriate to bill CPT code 77077 with modifier 50. Based on this information, we decided that Medicare rules for coverage of the joint survey (77077) have not been met. Therefore, we decided that the Plan does not have to waive the coinsurance for the cranial maxillofacial surgery (21299), head surgery (21499), and the office visit (99215) provided. Additionally, the Plan does not have to pay for the joint survey (77077) provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) rendered by the
OON provider on December 16, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the subsequent nursing facility care (99307) rendered by the OON provider on
December 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97167) provided on April 9, 2020.
You asked the Plan to pay for the occupational therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the billed services.
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 occupational therapy services. Our reviewer says that CPT code 97167 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records document that service was performed in a home health or hospice setting. 97167 is not the
most appropriate code to use to bill this service, therefore, this service is not eligible for reimbursement consideration. 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 occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (97167) provided on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from
October 9, 2020, to November 3, 2020.

You asked the Plan to waive the coinsurance for the Part B injections. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received Part B injections on the dates of service at issue in this appeal. The
Plan says that the correct coinsurance has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B injections
from October 9, 2020, to November 3, 2020. You have been asked to pay a 20% coinsurance for the Part B
injections, totaling $1187.22. The Part B injections fall within the Medicare Part B prescription drugs benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Please note, the
Plan's claims are processed in the order they are received, not in the order of the date the services were
rendered. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injections
provided from October 9, 2020, to November 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation for physical therapy, typically 45 minutes (CPT code 97163) provided to the enrollee on September 17, 2020, by a non-participating provider.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our physician 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 physician reviewer found the review has determined that the documentation submitted did not include documentation supporting a physical therapy evaluation of high complexity; therefore, the billed service cannot be verified. The submitted documentation does not include a clinical decision making of high complexity. It is noted that multiple attempts were made to contact the provider for additional information. The review has determined that the services were not supported by the records.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for evaluation for physical therapy, typically 45 minutes (CPT code 97163) provided to the enrollee on September 17, 2020, by a non-participating provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that it is necessary for you to have additional routine transportation trips beyond the Plan's benefit allows for. The Plan denied your request. The Plan says after 14 more trips, the benefit will be exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you after 14 trips you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist office visits (99203, 99213) to be provided by
an out of network provider.

You asked the Plan to pre-approve specialist office visits. You say that you are in a horrible amount of pain and
have not been able to see an in-network pain management provider. The Plan denied your request. The Plan
says rules for out of network care have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
specialist office visits (99203, 99213) to be provided by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for bronchoscopy (CPT 31641) services provided to the enrollee on June 8, 2020.

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 Current Procedural Terminology (CPT) code 31641 GC (1 unit) remains 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 31641 is "bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision." 

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 supported by the medical records. Our coding reviewer found the operative report documents a laryngoscope was used in the procedure. Therefore, there is a more appropriate code to use for 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 services have not been met. Therefore, we decided that the Plan does not have to pay for bronchoscopy (CPT 31641) services provided to the enrollee on June 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient therapy services provided from February 3, 2021 to February 25, 2021.
You asked the Plan to waive the copayments for the outpatient therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient therapy services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient
therapy services from February 3, 2021 to February 25, 2021. You have been asked to pay a $20 copayment for each outpatient therapy service, totaling $160. The outpatient therapy services fall within the Outpatient rehabilitation services 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 outpatient therapy services provided from February 3, 2021 to February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services (CPT 14040) provided to the enrollee on November 27, 2020.
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 Current Procedural Terminology (CPT) code 14040 is not supported by the medical records submitted.
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 14040 is "adjacent tissue transfer or rearrangement of the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; on defect 10sq cm or less." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the enrollee underwent a procedure on November 27, 2020. The operative note states an advancement flap was created. A rearrangement or transfer requires back cuts not merely undermining.
The operative note does not indicate back cuts or repair of secondary defect. The elements of the code have not been satisfied. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for plastic surgery services (CPT 14040) provided to the enrollee on November 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested care is a necessity for you. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B drugs, and the specialist services provided on February 3, 2021.

You asked the Plan to waive the cost share for the Part B drugs and the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received Part B drugs and services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and a $35 copayment for specialist services. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B drugs and services provided by a specialist on February 3, 2021. As you met your out-of-pocket maximum through part of the coinsurance applied for the Part B drugs, you have been asked to pay $996.98 of the remaining coinsurance along with a $35 specialist copayment to meet your out-of-pocket maximum. Medicare Part B prescription drugs fall within the Medicare Part B prescription drugs benefit category. Specialist services fall within the Physician/Practitioner services 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 cost share for the Part B drugs, and the specialist services provided on February 3, 2021.