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

We decided that the Plan does not have to pay for the morphometric analysis, tumor immunohistochemistry services coded 99360 provided on September 24, 2020.
You asked the Plan to pay for the morphometric analysis, tumor immunohistochemistry services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Review of the file shows that this service was billed with both the 59 modifier and the XU modifier. These modifiers represent interpretation by the same physician or a different physician and cannot be billed
together. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis, tumor immunohistochemistry services coded 99360 provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85060) provided December 31, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for separate payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 85060 is not supported in the medical record. Specifically, per the Physician Fee Schedule, separate payment may be made only if the physician interprets an abnormal smear for a hospital inpatient. The service was billed with a place of service 22, outpatient hospital. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (85060) provided December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on March 28, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration because the provider rendered medically necessary services in good faith. The Plan denied your request. The Plan says the record submitted supports one unit of CPT code 99309 which was already processed and paid.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing facility care have not been met. Specifically, the record shows that one unit of CPT code 99309 was previously processed and paid. The documentation submitted does not support that an additional unit of CPT code 99309 was rendered on the billed date of service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) received February 25, 2021.

You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that you would not have consented to receiving this service if you had been told it would not be covered. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

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 intraoral - complete series of radiographic images (D0210) received February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided March 22, 2021.

You asked the Plan to pay for the full mouth debridement. You say that the dental service was necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.

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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is 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 pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for gene expression analysis (81545) provided on January 9, 2021, by an out of network provider.

You asked the Plan to pay for gene expression analysis. You say that the requested service was a necessity for the care of the enrollee. 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 gene expression analysis (81545) provided on January 9, 2021, by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are a high fall risk and need interventions now. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are identified. While the enrollee may benefit from additional skilled therapy services, the documentation does not support that it is medically reasonable and necessary to receive these services on a daily basis on an inpatient basis in a skilled nursing facility. If necessary, the enrollee may continue to receive care at the Inpatient Rehab Facility. This patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on August 18, 2020.

You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation indicates that the services were performed by a physical therapist in a home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 1, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that this was a short telehealth visit and you were not examined and disagree with the copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each specialist visit. 

You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from October 23, 2020, through November 21, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says there are no daily skilled nurse or therapist needs.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral and topical medications and insulin. The enrollee had stable vital signs. The enrollee used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF at a non-skilled level of three times per week. Speech therapy (ST) evaluation recommended that the enrollee maintain a regular diet and thin liquids. By the dates in question, the enrollee required maximal assist for bed mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from October 23, 2020, through November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Maxima scooter, a vehicle lift, and a trifold ramp (E1399 x 3), as well as sales taxes for these items (S9999), purchased on August 29 to September 9, 2020.

You asked the Plan to pay for a Maxima scooter, a vehicle lift, a trifold ramp, and sales tax. You say that the requested items are necessary for your care. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you had another scooter at the time a Maxima scooter was received. Your other scooter serves the same purpose as a Maxima scooter. 

The rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

A vehicle lift and a trifold ramp are needed for use outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 

The rules also say that Medicare does not reimburse separately for sales tax.

Therefore, we decided that the Plan does not have to pay for a Maxima scooter, a vehicle lift, and a trifold ramp (E1399 x 3), as well as sales taxes for these items (S9999), purchased on August 29 to September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97530) provided August 11, 2020.

You asked the Plan to pay for the physical therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the correct CPT code was not billed for these 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the record shows the service was performed in the home setting. There is a more appropriate CPT code that describes therapy services performed in the home health setting (G0158).

Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97530) provided August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for ophthalmology services provided on December 22, 2020.

You asked the Plan to waive the deductible and copayment for ophthalmology services. You say that you disagree with the charges because this was a routine eye exam. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible. Your contract with the Plan also clearly says that after the $500 deductible has been met, enrollee's must pay a $10 copayment for specialist visits. 

You received ophthalmology services on December 22, 2020. Ophthalmology services are considered specialist services. The record shows that you had only paid $410.13 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $89.87. Now that the $500 deductible has been met, you are also responsible to pay the $10 copayment. The total amount you owe is: $99.87.

The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time ophthalmology services were received on December 22, 2020. Therefore, we decided that the Plan does not have to waive the deductible and copayment for ophthalmology services provided on December 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from December 4, 2020, through January 2, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.

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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a minimal to moderate assist level with functional mobility including gait to 60 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SN services provided from December 4, 2020, through January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiovascular services to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve cardiovascular services. You say that you would like to see this provider
because you have established care there. The Plan denied your request. The Plan says there are in-network
providers available for these services.

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
cardiovascular services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a monitoring feature or device, stand-alone or integrated (A9279), for a positive airway pressure device, provided on January 22, 2021.

You asked the Plan to pay for a monitoring feature or device. You say that the requested item helps you to manage your care. The Plan denied your request. The Plan says rules for payment have not been met because the requested item is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that a monitoring feature or device described by code A9279 is statutorily non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a monitoring feature or device have not been met. Therefore, we decided that the Plan does not have to pay for a monitoring feature or device, stand-alone or integrated (A9279), for a positive airway pressure device, provided on January 22, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99308) provided on October 12, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 service 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 physician services (99308) provided on October 12, 2020.