Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97116) provided to the enrollee on June 10, 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 there are more appropriate codes to use in this case.

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 the denied codes is: 

CPT 97110: 

therapeutic exercises to develop strength, endurance, range of motion and flexibility 

CPT 97116: 

Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)

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 documentation supports the services were performed in the enrollee's home; therefore, the services should be reported with the appropriate Healthcare Common Procedure Coding System (HCPCS) code. In this case; CPT 97110 and CPT 97116 would not be covered. HCPCS codes should be reported for services performed in the home health setting. 

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 services (97110, 97116) provided to the enrollee on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212), arthrocentesis, aspiration and/or
injection (20611), and the hyaluronan or derivative, for intra-articular injection (J7321) rendered by the out-ofnetwork
(OON) provider on January 19, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 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 office visit (99212), arthrocentesis, aspiration and/or injection (20611), and the hyaluronan or derivative, for intra-articular injection (J7321) rendered by the out-of-network (OON) provider on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (99214) provided on
March 18, 2021.

You asked the Plan to waive the copayment for a medical eye exam. You say that you had a routine eye exam,
and you don't understand why it is being billed as a medical eye exam. You also say that the provider is an
optometrist not an ophthalmologist. The Plan denied your request. The Plan says the copayment you are being
charged is correct.

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 a Medicare-covered exam to diagnose and treat diseases or conditions of the eye.

You have been asked to pay a $45 copayment for a medical eye exam. The records show you were treated for a
nuclear cataract. The EOC confirms $45 is the required copayment for this service. A medical eye exam falls
within the vision care benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a medical
eye exam (99214) provided on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and the enrollee is a good candidate. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/investigational.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show the safety and efficacy of this 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens tint and ultraviolet lenses provided on April 12, 2021, to April 13, 2021.
You asked the Plan to pay for lens tint and ultraviolet lenses. You say that you disagree with the denial. The Plan denied your request. The Plan says you exceeded the $150 vision allowance benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have a $150 allowance once per year to use towards eyewear. We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed benefit. The records also show you purchased frames at $85, lenses at $80, lens tint at $20 and ultraviolet lenses at $20, for a total amount of $205 ($85 + $80 + $20 + $20 = $205). The Plan applied your $150 allowance which left you with a balance of $55 ($205 - $150 = $55). The Plan also applied a 20% off discount, (20% of $55 = $11) which brings your total cost share to $44. Based on this information, we decided that the Plan's rules for coverage of lens tint and ultraviolet lenses have not been met. Therefore, we decided that the Plan does not have to pay for lens tint and ultraviolet lenses provided on April 12, 2021, to April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 28, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and the rules. In this case, the testing at issue was not billed as a single procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an opt-out provider on January 22, 2021.
You asked the Plan to pay for the visit. You say that you were told that this would be treated as an out-of-network claim. The Plan denied your request. The Plan says the rendering provider opted out of Medicare on July 17, 2010.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit provided by an opt-out provider on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic testing strips for high utilization testing.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that supplies for high utilization testing are covered when specific criteria are met. 

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 these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a diagnosis of diabetes due to an underlying condition with hyperglycemia. The records do not support that the enrollee's diabetes control and need for the specific quantity of supplies exceeds the usual utilization amounts. The services are therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic testing strips for high utilization testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where currently receiving 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 the LTACH services have not been met. Specifically, the enrollee is receiving appropriate care at the current facility. The LTACH does not offer any additional medically necessary services that they are not already getting. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on February 9, 2021 to March 10, 2021.
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that your primary care provider must give you approval in advance before you can see other provider's in the plan's network
The Plan did not pre-approve the item/service at issue. There was no referral provided from your primary care provider indicating that prior authorization was requested for these services you received. 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 the home health services provided on February 9, 2021 to March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography, lower extremity; without contrast material (73700) rendered by the out-of-network (OON) provider on February 11, 2021.

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 computed tomography, lower extremity; without contrast material (73700) rendered by the out-of-network (OON) provider on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 4, 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 office visit (99214) rendered by the out-of-network (OON) provider on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the requested oral surgery with a non-contracted provider.

You asked the Plan to pre-approve the requested oral surgery with a non-contracted provider. You say that the requested oral surgery is medically necessary to prepare your mouth for dentures. The Plan denied your request. The Plan says that the requested services would be covered if performed by a contracted provider.

Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. 

The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers located within reasonable distance and travel time from your home who can provide the requested oral surgery. The file shows that the Plan only has one contracted dental provider who is not taking any new patients until 2022. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve the requested oral surgery with a non-contracted provider.

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 the physician services (99213) provided on November 8, 2020.
You asked the Plan to pay for the physician services (99213). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the Plan does not have to pay for the physician services (99213) provided on November 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on January 4, 2021.

You asked the Plan to pay for the laboratory services (G0483). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0483) provided on January 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99282) provided
on April 5, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit provided. 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 emergency room visit (99282) provided on
April 5, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for selective catheter placement, arterial system, provided on September 14, 2020.

You asked the Plan to pay for selective catheter placement, arterial system (36215). You say that medical rationale is substantiated and documented to support the arterial catheter advancement. The Plan denied your request. The Plan says that procedure code 36215-59 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 36215 is selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. 

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 selective catheter placement, arterial system (36215). Our reviewer says that documentation submitted was reviewed and does meet criteria. Our physician reviewer found documentation includes selective catheter placement for arteriogram to evaluate for inflow stenosis. Per CPT guidelines "For the purposes of reporting dialysis access maintenance services, the arterial inflow to the dialysis circuit is considered a separate vessel." This rule can be found in Current Procedural Terminology, under interventions through dialysis circuit. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of selective catheter placement, arterial system (36215) have been met. Therefore, we decided that the Plan has to pay for selective catheter placement, arterial system, provided on September 14, 2020.

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.