Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for specialist services provided by a participating provider on August 13, 2020.

You asked the Plan to waive the coinsurance for an injection and copayment for specialist services. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance and copayment have been applied.

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/in-network and a $40 copayment for physician/practitioner services/in-network/provider and professional services/specialist.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $40 copayment for specialist services. The total allowed amount is $483.24. The total amount you are being asked to pay for an injection is $96.65 ($483.24 x 20% = $96.65). The total amount you are being asked to pay is $136.65 ($40 + $96.65 = $136.65). An injection falls within the Medicare Part B prescription drugs/in-network benefit category. Specialist services fall within the physician/practitioner services/in-network/provider and professional services/specialist 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 an injection and copayment for specialist services provided by a participating provider on August 13, 2020.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for repair of an abdominal aortic aneurysm. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional skilled nurse home visits.
You asked the Plan to pre-approve the additional home visits. The Plan denied your request. The Plan says the skilled nursing visit is for Foley catheter care and exchange, which occurs once a month. The Plan also says that no records were provided as to why more frequent skilled nursing visits were required.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 additional home visits. Our reviewer says that the frequency of requested HH RN services is not shown to be medically necessary and reasonable. Our physician reviewer found the enrollee has the need for monthly catheter care. Our reviewer found that the enrollee does not have documented intravenous or wound care needs. Our physician reviewer found also that there is no documentation of frequent medication changes. 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 additional home visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional skilled nurse home visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring provided on
January 11, 2021.
You asked the Plan to pay for short-latency somatosensory evoked potential study, stimulation of any/all
peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs
(95938TC). You say that the place of service is accurately reported. The Plan denied your request. The Plan
says the billed place of service is not supported.
The Plan must follow Medicare rules. Medicare rules say that when completing the 1500 claim form, providers
must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be
denied and returned to the provider.
In this case, code 95938 cannot be paid as billed due to an error with the POS code reported. The
documentation indicates the enrollee received services in a facility setting. Payment for this service is included
in payment to the facility and not separately reimbursable. Medicare billing criteria are not met. Therefore, we
decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring provided on
January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230 x3) provided on January 4, 2021.

You asked the Plan to pay for intraoral periapical radiographic images. You say that you were told the services at issue were coded incorrectly. The Plan denied your request. The Plan says the services at issue are not covered 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 intraoral periapical radiographic images (D0220, D0230 x3) provided on January 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an MRI scan of the brain stem (70553) and an MRI scan of the spine of the chest (72157) performed on January 15, 2021.

You asked the Plan to waive the copayments for an MRI scan of the brain stem and an MRI scan of the spine of the chest. You say that the date of service should have one copayment of $250 since you went in and had all imaging done at one time. You also say that you were not advised by the referring provider's office that you would have two separate copayments instead of one. The Plan denied your request. The Plan says the correct copayments were applied.

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 $250 copayment for each Medicare-covered diagnostic imaging service.

You have been asked to pay a $250 copayment per scan for an MRI scan of the brain stem and an MRI scan of the spine of the chest. An MRI scan of the brain stem and an MRI scan of the spine of the chest 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 an MRI scan of the brain stem (70553) and an MRI scan of the spine of the chest (72157) performed on January 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the enrollee will greatly benefit from skilled nursing. The Plan denied your request. The Plan says that the member does not require the daily skilled therapy or nursing services.

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 that the enrollee's condition does not meet Medicare criteria for SNF services. 

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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on February 1, 2021.

You asked the Plan to pay for occupational therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy (OT) services rendered on May 27, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97167 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 97167 is occupational therapy evaluation, high complexity, typical time with patient 60 minutes. 

We find that CPT code 97167 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy (OT) services rendered on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (EEG) provided to the enrollee on
September 22, 2020.
You asked the Plan to pay for the EEG. You say that this should be paid for. The Plan denied your request. The
Plan says Current Procedural Terminology (CPT) code 95819-26 (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 95819 is "Electroencephalogram (EEG); including
recording awake and asleep."
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 EEG. Our reviewer says that the services
at issue in this case were not supported by the medical records. Our coding reviewer found the documentation
did not include an EEG including recording awake and asleep.
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 EEG have not been met. Therefore, we decided that the Plan does not have
to pay for an electroencephalogram (EEG) provided to the enrollee on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a complete upper denture (D5110), and a complete lower denture (D5120) provided on November 2, 2020.

You asked the Plan to pay an additional amount for a complete upper denture, and a complete lower denture. You say that the services at issue should be covered. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture, and a complete lower denture have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a complete upper denture (D5110), and a complete lower denture (D5120) provided on November 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional home health OT visits.

You asked the Plan to pre-approve four (4) additional home health OT visits. You say that additional home health OT is medically necessary. The Plan denied your request. The Plan says additional home health OT is not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 four (4) additional home health OT visits. Our reviewer says that additional home health OT is not medically necessary or reasonable. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. You appear to be doing well with activities of daily living. You require minimal assistance and supervision, and you have family members willing and able to help. As such, the frequency and quantity of requested home health OT services is not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of four (4) additional home health OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional home health OT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultraviolet light therapy system (E0691), a lumbar-sacral orthosis (L0648), and a knee brace (L1852) provided on February 9, 2021.
You asked the Plan to pay for an ultraviolet light therapy system, a lumbar-sacral orthosis, and a knee brace. You say that the items at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery is not itemized nor does the document correspond to the provided itemized invoice. The provided document does not corroborate that the supplies at issue in this case were provided to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an ultraviolet light therapy system (E0691), a lumbar-sacral orthosis (L0648), and a knee brace (L1852) provided on February 9, 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 the records provided support the need for IRF care. The Plan denied your request. The Plan says IRF care is not supported based on the records received.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for septic arthritis of the knee. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 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 services provided on November 12, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services was not filed until March 1, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure services coded 95999 provided on December 14, 2020.

You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure 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 not payable.

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 95999 is unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that the enrollee underwent back surgery requiring neurophysiology monitoring. These services are considered a bundled procedure as the cost is included in the cost of the primary procedure. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure services have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure services coded 95999 provided on December 14, 2020.