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

We decided that the Plan does not have to pay for critical care services (99291) and closed treatment of a distal radial fracture (25605) provided on October 13, 2020.

You asked the Plan to pay for the critical care services and fracture treatment. You say that you would like reconsideration because this claim was billed correctly. The Plan denied your request. The Plan says these services were not billed with appropriate diagnosis codes and modifiers.

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 asked our coder 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 critical care services and fracture treatment. Our reviewer says that CPT 99291 was billed with diagnosis of Z11.59 - Encounter for screening for other viral diseases which does not indicate the patient was being treated for a disease, they were being screened for a viral disease. This diagnosis is not appropriate to bill with CPT 99291 because it is considered a routine screening and not a critical care service, therefore 99291 cannot be validated based on the diagnosis code associated with it. Our reviewer found 25605 was not billed with a modifier of LT to indicate which side the service was performed. CPT 26505 has a bilateral indicator of "1" and requires a modifier to indicate which side of the body the service is performed. Based on the diagnosis an LT needed to be appended to this service. Because and LT was not appended to this service, it is not eligible for reimbursement consideration. 

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 critical care services and fracture treatment have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) and closed treatment of a distal radial fracture (25605) provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 30, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.

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 laboratory services. 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 laboratory services provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions provided on October 28, 2020 by an OON provider.

You asked the Plan to pay for the extractions. You say that when you enrolled with this plan you were told that this provider would be in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON 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 covered when they are received OON. The record shows that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for the two extractions provided on October 28, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyelid repair (67904).

You asked the Plan to pre-approve eyelid repair. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered cosmetic.

The Plan follows Medicare rules. Medicare rules say that functional blepharoplasty procedures and surgical procedures of the brow will be considered medically reasonable and necessary in the situations described in the LCD. 

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 eyelid repair. Our reviewer says that the requested procedure is not shown to be necessary at this time. Our physician reviewer found the taped and untaped visual field determinations do not demonstrate that there is greater than a 30% loss in upper field vision. The documentation as presented does not provide evidence to satisfy the remaining elements of the local coverage determination. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eyelid repair have not been met. Therefore, we decided that the Plan does not have to pre-approve eyelid repair (67904).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
October 19, 2020.

You asked the Plan to pay for the dental service. You say that this was the first time seeing this dentist. You
say that they had to do a thorough exam, as indicated under the circumstances. You say that your previous
dentist retired, and you had a poor experience with the provider that took over for them. You also say that this
service should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is
covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

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 and comprehensive oral evaluation is
listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the
comprehensive oral evaluation that you received on November 26, 2018. Therefore, we decided that the Plan
does not have to pay for the comprehensive oral evaluation (D0150) provided on October 19, 2020.

Your complaint about your previous denitst is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of a nasal bone fracture (21310) provided on March 14, 2020.

You asked the Plan to pay for the closed treatment of a nasal bone fracture. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 asked our coder 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 closed treatment of a nasal bone fracture. Our reviewer says that CPT code 21310 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records do not include documentation of a Closed treatment of nasal bone fracture without manipulation being performed on March 14, 2020, therefore this service cannot be verified. 

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 closed treatment of a nasal bone fracture have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of a nasal bone fracture (21310) provided on March 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on July 17, 2020.

You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because this service was reported correctly. The Plan denied your request. The Plan says the documentation does not support the level of service billed.

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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an 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 department visit. Our reviewer says that CPT 992985 requires the documentation of a comprehensive history, comprehensive examination and high-complexity medical decision making. Our physician reviewer found the documentation does not note a comprehensive history, comprehensive examination or high-complexity medical decision making. 

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 department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided on July 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 18, 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 these procedures as billed are not recommended for separate reimbursement.

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 64400: 

Injection(s), anesthetic agent(s) and/or steroid 

CPT 21073: 

Manipulation of hinged joints of upper and lower jaw bones under anesthesia 

CPT 20605: 

Arthrocentesis, aspiration and/or injection 

CPT 99152: 

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 

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 documented submitted was reviewed, and the services do not meet the coding criteria. The procedure report does not include description of the denied procedures to confirm that they have been performed. 

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 surgical services provided to the enrollee on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous passive motion device (CPM)(E0935).

You asked the Plan to pre-approve the CPM. You say that the CPM is required. The Plan denied your request. The Plan says because this member has not had knee replacement surgery, Medicare criteria have not been met.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 

You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve continuous passive motion device (CPM)(E0935).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered on October 21,
2019.

You asked the Plan to waive the copayment for these services. You say that you included EOBs from your
previous plan and are being billed for the charges. The Plan denied your request. The Plan says the copayment
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 $45
copayment for in-network Medicare-covered vision services in a specialist's office.

Review of the file shows that you received an eye exam on October 21, 2019. You have been asked to pay a
$45 copayment for these services. These services fall within the in-network Medicare-covered vision services
in a specialist's office 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 the eye
exam rendered on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 4, 2020.

You asked the Plan to waive the copayment for the office visit. You say that you had your annual physical and have never had to pay a copayment in the past. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for PCP office visit/other health care professionals. 

You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/ Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for an arthritis follow-up visit. 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 office visit provided on November 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from
December 1, 2020, to December 2, 2020.

You asked the Plan to waive the copayment for the observation stay. You say that you were fully admitted to
the hospital and not in observation status. You say you would like the copayment waived. The Plan denied your
request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65
copayment for Medicare-covered outpatient hospital observation services.

You have been asked to pay a $65 copayment for the observation stay. The observation stay falls within the
"Outpatient Hospital Observation Services" benefit category. The medical record shows you were admitted for
observation and management. 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 observation stay
provided from December 1, 2020, to December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compressor (E0570) provided on October 9, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the nebulizer with compressor. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for this non-emergent service.

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 nebulizer with compressor (E0570) provided on October 9, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the abdomen.

You asked the Plan to pre-approve MRI of the abdomen. You say that you would like reconsideration because the MRI is medically necessary to address the member's adrenal gland nodule seen on prior computed tomography. The Plan denied your request. The Plan says this is not the standard of care.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

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 MRI of the abdomen. Our reviewer says that the review has determined that the requested MRI is not medically reasonable or necessary. Our physician reviewer found MRI can be useful in evaluation of the following Ischemia/infarct, vascular anomalies, hemorrhage, infection, tumors and masses, trauma and diffuse axonal injuries, neurodegenerative disorders and dementias, and inflammatory conditions. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mastectomy bra provided on August 28,
2020.

You asked the Plan to waive the deductible for the mastectomy. You say that you were under the impression
that medical supplies would be covered and would only be 10% of the entire cost. The Plan denied your
request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is an $800 deductible that applies towards the mastectomy bra.

The mastectomy bra you asked the Plan to waive the deductible for falls within the "Prosthetic devices and
related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract
that there is an $800 deductible that applies towards the mastectomy bra. This cost sharing is a contractual
obligation that had not been met at the time the mastectomy was received on August 28, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for the mastectomy bra provided on August 28,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 1, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 laboratory services. 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 laboratory services provided on October 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the robotic surgical services (S2900) provided on October 9, 2020.

You asked the Plan to pay for the robotic surgical services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this 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. 

We find that CPT code S2900 is not supported in the record. Specifically, CPT code S2900 is not valid for Medicare purposes. No additional payment may be made for this service. Based on this information, we decided that Medicare rules for coverage of the robotic surgical services have not been met. Therefore, we decided that the Plan does not have to pay for the robotic surgical services (S2900) provided on October 9, 2020.