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

We decided that the Plan does not have to pay for emergency department visit (99285) provided November 11, 2020.

You asked the Plan to pay for the emergency visit. You say that kindly review the complete attached medical records to prove the medical necessity for the service and reprocess the claim towards payment. The Plan denied your request. The Plan says the documentation only substantiated a moderate level of decision making. 99285 is not supported, however, the claim was reprocessed to pay at a lower level of care for 99284.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. 

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):

1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 

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 emergency visit. Our reviewer says that the requested items/services is not supported by the medical records. Our reviewer found the emergency room visit documents a comprehensive history and exam, however, data reviewed is a computed tomography, chest x-ray and labs, which support moderate complexity. Presenting problems are of high complexity, therefore, a medical decision making is of moderate risk and the more appropriate code to report is CPT 99284. 

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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for emergency department visit (99285) provided November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you never had these services, and this is fraud. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer 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 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. Evidence was provided that shows that lab work was provided on the date of service in question. 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 lab work provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 5, 20202.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on October 5, 20202.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 22, 2021
through March 5, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you don't understand what the charges
are for or why you were charged the entire amount. The Plan denied your request. The Plan says the selfadministered
medications denied correctly as non-covered services.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided on February 22, 2021 through March 5, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you feel this is medically necessary to improve your condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report (CPT code 91111) and gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (CPT code 91110), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services should be approved. The Plan denied your request. The Plan says they need more information, such as the enrollee's doctors' notes, lab tests, and results of other tests such as upper endoscopy and colonoscopy.

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 services. Our physician reviewer found the record indicates that the enrollee has melena. A colonoscopy was performed that did not reveal a bleeding source. An upper endoscopy has not yet been performed. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report (CPT code 91111) and gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (CPT code 91110), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on January 16, 2021.
You asked the Plan to pay for the ambulance service. You say that your primary care physician (PCP) called the ambulance to take you from the assisted living facility to the hospital for lab testing. You also say that you feel this should be covered since it was your doctor that called for the ambulance. The Plan denied your request. The Plan says the claim processed correctly according to the billing by the provider for the services rendered. The Plan also says that ambulance response and treatment with no transportation is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 16, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on January 16, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for hyponatremia, dehydration, and Parkinson's disease. Your medical problems are stable.
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on February 22, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95886 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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).
We find that CPT code 95886 is not supported in the medical record. Specifically, there is no documentation of needle electromyography. 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 testing services rendered on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided February 5, 2021, surgical stent (D5982) provided March 3, 2021, autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273) and unspecified preventive procedure, by report (D1999) provided April 16, 2021.

You asked the Plan to pay for the limited oral exam, surgical stent, autogenous connective tissue graft and unspecified preventative procedure. You say that the procedure was medically necessary, and you would like the Plan to rethink the denial. The Plan denied your request. The Plan says you are only enrolled in an optional preventative dental benefit and these services are not covered under the 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 limited oral exam (D0140) provided February 5, 2021, surgical stent (D5982) provided March 3, 2021, autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273) and unspecified preventive procedure, by report (D1999) provided April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) provided on October 30, 2020.
You asked the Plan to pay for a knee brace. You say that the item at issue is 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 can the document be determined to correspond to the provided itemized invoice. 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 a knee brace (L1833) provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction provided on March 3, 2021.
You asked the Plan to pay for refraction. You say that you need prescription sunglasses so the refraction should be covered. The Plan denied your request. The Plan says the refraction was done as a medical exam.
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 covers these services when routine refractive eye exams are for prescription eyeglasses. We looked at the file and the Plan's rules. The record shows this was a medical exam due to visual disturbances not a routine refraction for an eyeglass prescription. Based on this information, we decided that the Plan's rules for coverage of refraction have not been met. Therefore, we decided that the Plan does not have to pay for refraction provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and periodontal maintenance (D4910) provided on March 11, 2021.

You asked the Plan to pay an additional amount for a periodic oral evaluation, bitewing radiographic images, and periodontal maintenance. You say that the services at issue should be covered. The Plan denied your request. The Plan says the provider was paid at the 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 periodic oral evaluation, bitewing radiographic images, and periodontal maintenance 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 periodic oral evaluation (D0120), bitewing radiographic images (D0274), and periodontal maintenance (D4910) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on February 23, 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 office visit (99215) rendered by the out-of-network (OON) provider on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on January 21, 2021.

You asked the Plan to pay for the services. You say that this should be covered. The Plan denied your request. The Plan says this request represents apparent claim unbundling.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 the Guardant360 test provided to the enrollee on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided from December 8, 2020, to December 24, 2020.
You asked the Plan to waive the copayment for the inpatient care. You say that you received two bills for the same hospital stay, which started on December 4, 2020, and you should only have one copayment. The Plan denied your request. The Plan says the cost-sharing for the inpatient services was 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 $325
copayment for each of the first five days of a Medicare-covered hospital admission. This hospital cost sharing
will apply each time you are admitted. This includes when transferring from one facility to another or transferring within the same facility between levels of care.
You have been asked to pay a $1,625 copayment for the inpatient rehabilitation care that started on December 8, 2020. Your inpatient admission exceeded five days, but you have only been charged the copayment for the
first five days as dictated by the contract. ($325 copayment x 5 days = $1,625). You say that you should not be billed two copayments for this hospital stay because you were in the same facility from December 4, 2020, to December 24, 2020. Documentation shows that you remained in the same facility, but on December 8, 2020, you were transferred from an acute inpatient level of care to an inpatient rehabilitation level. The contract states that inpatient hospital cost sharing will apply each time you are admitted. This includes when you transfer to
another level of care within the same facility.
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 inpatient rehabilitation services provided from December 8, 2020, to December 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Stelara (J3357).

You asked the Plan to pre-approve Stelara. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Stelara (J3357).

Benefits for Stelara may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.