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

We decided that the Plan does not have to pay for a microscopic genetic analysis of a tumor (88361) provided on December 18, 2020.

You asked the Plan to pay for laboratory testing. You say that testing was ordered after the ordering physician made a professional determination of medical necessity. You also say you are seeking reconsideration. The Plan denied your request. The Plan says services were not medically necessary.

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 pay for laboratory testing. Our reviewer says that the provided records did not indicate a need for this additional testing and there is insufficient evidence to support its use in this specific clinical situation to show an overall improved outcome. Therefore, this request for WATS 3D Biopsy will be considered not medically necessary. Our physician reviewer found the patient is a 69-year-old female with Barrett's esophagus. She underwent EGD with cytology brushings (biopsy). Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology (88361) was requested.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for a microscopic genetic analysis of a tumor (88361) provided on December 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on October 31, 2020.

You asked the Plan to pay for the ambulance services. You say that your blood sugar dropped quickly, and you became unresponsive. You say that your daughter called 911. You also say that without this medical intervention, you would have died. The Plan denied your request. The Plan says Medicare does not cover ambulance services when there is no transport.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 31, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.

Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on October 31, 2020.
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 enrollee needs to work on strength and endurance. The Plan denied your request. The Plan says the enrollee has plateaued with progress.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing or therapy needs. He appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on February 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on February 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent hospital care represented by code 99233 provided on January 20, 2021.

You asked the Plan to pay for code 99233. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the medical records do not support the billing of code 99233.

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 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 

We find that CPT code 99233 is supported in the medical record. Specifically, the medical records show that a detailed history, detailed examination and medical decision making of high complexity was made. Based on this information, we decided that Medicare rules for coverage of code 99233 have been met. Therefore, we decided that the Plan has to pay for the subsequent hospital care represented by code 99233 provided on January 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing subsequent care provided on March 8, 2021, to April 19, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for skilled nursing subsequent care. You say that you received several notice of denials of payment and believe these claims should be paid. The Plan denied your request. The Plan says services were provided 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 requested provider in this case is not a network provider with the Plan. The records provided for review also show that the enrollee was referred by a non-participating provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing subsequent care provided on March 8, 2021, to April 19, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to reimburse an additional amount for the crown, bitewing x-rays, and oral evaluation. We decided that the Plan does not have to reimburse you in full for the dental services.

You asked the Plan to reimburse you for the crown, bitewing x-rays, and oral evaluation. You say that at least some of the services are covered. You say that your primary insurance covered some of the services, but your secondary insurance covered nothing. You also say that some payment should be made by your secondary dental insurance. The Plan says that out of network providers may bill you any amount over the maximum allowable charge. The Plan also says that the frequency limits for oral exams and bitewing x-rays have 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. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

We decided that the Plan has to reimburse an additional amount for the crown, oral exam, bitewing x-ray, and the periapical x-ray.

The record shows that you received a crown and the primary payer paid $614. The Plan is contractually obligated to make payment for covered services up to the maximum allowable charge (MAC). Any payments made by another entity cannot be considered to meet this obligation. After primary payment, you owe $840, which exceeds the Plan's MAC for this service. As such, the Plan must pay the $492 toward the remaining cost of this service. Additionally, there was no documentation provided which substantiated the claim that the frequency limits had been met for the oral exam, bitewing x-rays, and periodontal maintenance. Although the record shows that the Plan paid for periodontal maintenance performed on September 10, 2020, this does not exhaust the benefit. Therefore, we decided that the Plan has to reimburse you an additional amount for the crown, oral exam, bitewing x-ray, and periapical x-ray.

We also decided that the Plan does not have to reimburse you in full for the dental services.

The Plan is only responsible for paying up to the MAC for covered services. The contract says that for services obtained OON the Plan only pays up to a certain amount. If you choose to see an OON dentist, you might be billed for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to reimburse you in full for the dental services.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible assessed for medical services performed in an ophthalmologist's office on February 19, 2021, and March 5, 2021.

You asked the Plan to waive the deductible assessed for the ophthalmology services. You say that you do not understand why the charges for these services are different if the same codes are billed. The Plan denied your request. The Plan says the patient had not met their deductible at the time of these services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1250 deductible for services performed in a specialist's office. 

The deductible applies to the services provided in the ophthalmologist's office. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1250 deductible for services performed in a specialist's office. This cost sharing is a contractual obligation that had not been met at the time the ophthalmology services was received on February 19, 2021 to March 5, 2021. As a note, the reason why one of the codes on the claims is double the cost of the others is because it was billed with the -51 modifier. That modifier means that multiples of that same procedure code were performed at the same time, which would account for the double price. Therefore, we decided that the Plan does not have to waive the deductible assessed for medical services performed in an ophthalmologist's office on February 19, 2021, and March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mechanism to convert a manual wheelchair to a joystick-controlled power mobility device (E0983).

You asked the Plan to pre-approve a mechanism to convert a manual wheelchair to a joystick-controlled power mobility device. You say that the enrollee needs this item. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that an add-on to convert a manual wheelchair to a joystick-controlled power mobility device (E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not reasonable and necessary.

We looked at the file and Medicare rules. The requested item is not considered reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a mechanism to convert a manual wheelchair to a joystick-controlled power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a mechanism to convert a manual wheelchair to a joystick-controlled power mobility device (E0983).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on November 25, 2020.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you do not feel you should be responsible for this amount since your last colonoscopy was in 2015. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($388.99) is less than your copayment obligation, you are responsible for the full allowed 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 $395 copayment for outpatient surgery. 

Records show that your provider billed this as a diagnostic, not screening, colonoscopy. Diagnostic colonoscopies are considered surgical services. You have been asked to pay a $395 copayment for the diagnostic colonoscopy. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.

Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) provided May 4, 2021.

You asked the Plan to pay for the office visit. You say that you believe that an annual exam of a patient should be covered as monitoring and recording vitals are important in patient care. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

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 the outpatient office visit (99212) provided May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic assay rendered on February 3,
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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight
Psychotropic assay rendered on February 3, 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 you need intensive acute therapy to regain maximum functioning ability and to rebuild strength and endurance. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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.

The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for hypocalcemia and acute on chronic kidney injury. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 10, 2021, billed with codes 44500 and 30999.

You asked the Plan to pay for the medical services as billed. You say that these services should be paid in full. The Plan denied your request. The Plan says these codes are for services that are bundled into payment for other 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.

In this case, the CPT Code Manual definition of code 30999 is Unlisted procedure, nose. The definition of code 44500 is Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate 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 medical services as billed. Our reviewer says that the billed codes are not supported by the records. Our reviewer found for code 44500, the medical records provided do not include sufficient documentation to validated that an Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) was performed on March 10, 2021, therefore this procedure cannot be verified. For code 30999, this code was billed by the provider to represent a septal strap to keep the nasogastric (NG) tube in place. However, the code billed by the provider (44500) to represent the tube placed, also does not meet criteria for reimbursement consideration, as the provider placed a Corpak instead of a Miller-Abbott. As a result, 30999 is not eligible for separate reimbursement consideration as it would be already be included in the hospital reimbursement for placing an NG tube (Corpak). 

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 medical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 10, 2021, billed with codes 44500 and 30999.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a
pneumatic appliance (E0673) provided on August 27, 2020.

You asked the Plan to pay for an intermittent limb compression device and a pneumatic appliance. You say that
the requested items were a medical necessity for the enrollee for the prevention of deep vein thrombosis and
pulmonary embolism. The Plan denied your request. The Plan says pneumatic compression devices are not
covered by Medicare for prevention of deep vein thrombosis and pulmonary embolism.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression
device (E0675) and a pneumatic appliance (E0673) provided on August 27, 2020.