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

We decided that the Plan does not have to pay for a psychotherapy visit provided by a certified social worker (LCSW) on January 5, 2021.

You asked the Plan to pay for office visit. You say that disruption of service would be detrimental to the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is not covered.

The Plan must follow Medicare rules. Medicare rules say that a certified social worker is not eligible to enroll in Medicare and is therefore not payable.

We looked at the file and Medicare rules. This provider is not eligible to enroll in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided by a certified social worker (LCSW) on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy services coded 55214 provided on
October 17, 2020.
You asked the Plan to pay for the cystourethroscopy 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 supported by the
documentation.
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 55214 is cystourethroscopy, with fulguration (including
cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands.
We find that CPT code 55214 is not supported in the medical record. Specifically, the documentation submitted
did not include documentation of Cystourethroscopy, with fulguration (including cryosurgery or laser surgery)
of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands; therefore, the billed service cannot be
verified. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy
services have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy
services coded 55214 provided on October 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 29, 2020.

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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on March 5, 2021.

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 the claim was billed with an inappropriate place of service.

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 71045 is "Radiological examination, chest." 

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 submitted confirms the claim was paid for inpatient for the dates of service March 4, 2021 to March 6, 2021. Therefore, CPT 71045 was billed with incorrect place of service, and would not be covered.

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 radiology services (CPT 71045) provided to the enrollee on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on October 17, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. In this case, there were insufficient medical records from the treating physician that shows the results of the testing would be used in the management of a specific medical problem. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 18, 2020.

You asked the Plan to pay for the office visit. You say that you were unfamiliar with the requirements of the insurance and did not know you had to get authorization. You say that you wanted to give the patient the best possible care and the claim should be considered for payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 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 the office visit provided by an out-of-network provider on December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an inpatient hospital stay provided on January 24, 2021, to January 26, 2021.

You asked the Plan to waive the co-payment for an inpatient hospital stay. You say that you were transported to the emergency room by ambulance and admitted into the hospital for surgery. You also say the co-payment should be waived. The Plan denied your request. The Plan says the co-payment 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co-payment for inpatient hospital care.

You have been asked to pay a $300 co-payment for an inpatient hospital stay. The EOC confirms that each time you are admitted to an acute care hospital, you pay a $300 co-payment. 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 co-payment for an inpatient hospital stay provided on January 24, 2021, to January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided on November 23, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the OON x-ray services. You say that the services in dispute were medically necessary. You say that you were contacted by the contracted nursing facility to provide a portable exam. The Plan denied your request. The Plan says the OON care was 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 records do not show that the xray
services in dispute were provided in an emergent or out of area urgent care situation. The Plan did not preapprove
the OON x-ray services at issue. The case file shows that the referring nursing facility and the referring
provider are both non-contracted with the Plan. We found no exception that would require the Plan to pay for
the OON x-ray services. Therefore, we decided that the Plan does not have to pay for x-ray services provided
on November 23, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on February 12, 2021.

You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that the required copayment is beyond your means. The Plan denied your request. The Plan says the correct copayment was 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 $300 copayment for CT scans. 

You have been asked to pay a $300 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis falls 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 copayment for a CT scan of the abdomen and pelvis (74177) provided on February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on October 14, 2020.

You asked the Plan to waive the copayment for the ultrasounds. You say that you've had this examination for the last 15 years and never had to pay a copayment. The Plan denied your request. The Plan says the copayment applied correctly.

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 $60 copayment for Medicare-covered x-ray and ultrasounds from an in-network provider.

You have been asked to pay a $60 copayment for the ultrasounds. The ultrasounds fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasounds are considered a diagnostic service. 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 ultrasounds provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and routine venipuncture provided by an out-of-network provider on November 26, 2019, December 19, 2019, and December 30, 2019.

You asked the Plan to pay for the office visits and routine venipunctures. You say that you were sent there by another doctor and were not aware you would get a bill. You say that you want the bill investigated and you will not go out-of-network again. The Plan denied your request. The Plan says you must receive your care from a network provider.

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 the office visit and routine venipuncture provided by an out-of-network provider on November 26, 2019, December 19, 2019, and December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 13, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.

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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no specific clinical rationale for the obtained genetic testing. In addition, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. The requested genetic testing in this case is not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on January 25, 2021.

You asked the Plan to pay for code 99153. 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 and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) (code K0554) and related supply allowance (code K0553).

You asked the Plan to pre-approve therapeutic CGM and related supply allowance. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above. 

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 therapeutic CGM and related supply allowance. Our reviewer says that the requested service is not recommended. Our physician reviewer found the record does not indicate that you are on insulin, and you only check your sugar twice daily. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM and related supply allowance have not been met. Specifically, you are not on insulin, nor do you check your sugar the required daily four or more times. This means the coverage criteria for these items are not met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) (code K0554) and related supply allowance (code K0553).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the rules for SNF care have not been met.
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 while there are identifiable skilled therapy
service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not
require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary 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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, basic life support, emergency transport.
(A0429, A0425) provided on November 23, 2020.

You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429, A0425). You
say that the transport was medically necessary. The Plan denied your request. The Plan says that the ambulance
transport was not medically necessary. The enrollee could have been safely transported by another type of
motor vehicle, possibly a van transport vehicle.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.

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 ambulance service, basic life support,
emergency transport (A0429, A0425). Our reviewer says that the ambulance transport was medically
necessary. Our physician reviewer found that in this case, emergency services was called by the family of the
enrollee due to altered mental status and possibly blood per rectum. The enrollee was noted to be tachycardic.
Altered mental status would lead a prudent layperson to believe that immediate medical attention is warranted
to prevent serious jeopardy to health. The elements of the coverage rule are satisfied The requested service is
recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, basic life support, emergency transport (A0429, A0425)
have been met. Therefore, we decided that the Plan has to pay for ambulance service, basic life support,
emergency transport (A0429, A0425) provided on November 23, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 10, 2020 to September 11, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that you followed the necessary guidelines to ensure this enrollee received the appropriate required quality medical care. You are requesting prompt reprocessing of this claim for payment. The Plan denied your request. The Plan says inpatient admission was not medically necessary and did not meet the criteria for inpatient level of stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department with dislodgement of the hemodialysis catheter in the right upper chest area. A referral was made to Interventional Radiology for dialysis access, and the enrollee underwent tunneled dialysis catheter placement the following day. There were no complications. The enrollee reported to nursing that the Nephrologist, told her she did not need dialysis and could go home after the procedure. Nursing contacted the Nephrologist, and documented the physician confirmed the patient was cleared for discharge after the procedure and did not need dialysis before being released. Nursing spoke with attending, advising the patient was leaving AMA, but did not request a phone order for discharge. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided September 10, 2020 to September 11, 2020.