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

We decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on September 9, 2019.
You asked the Plan to pay for the advance care planning 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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of advance care planning including the explanation and discussion of advance directives such as standard forms. Based on this information, we decided that Medicare rules for coverage of the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on October 16, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service would be included in the payment to the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. This means that payment to you for this service is the responsibility of the facility. 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 perfusionist services provided to the enrollee on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit or the laboratory work provided on December 2, 2019.
You asked the Plan to waive the deductible for the office visit and the laboratory work. You say that this amount is too high. You say you were not told the provider is out-of-network. The Plan denied your request. The Plan says you have been charged 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 a $750 out-of-network deductible that applies towards out-of-network primary care physician services and out-of-network Medicare-covered outpatient lab services. The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 out-of-network deductible that applies towards out-of-network primary care physician services and out-of-network outpatient lab services. The record shows the provider is out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the office visit and the laboratory work were received on December 2, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit or the laboratory work provided on December 2, 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 December 11,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you fell off the bed while at the
doctor's. You say that the office should have to pay the claim. 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 $10
copayment per visit for an in-network primary care physician.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" 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 office visit provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November 21, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Glider for the enrollee.
You asked the Plan to pre-approve the Life Glider. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not indicate that a standard rollator walker or walker with a trunk support system will not meet the enrollee's mobility needs.
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 the Life Glider. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication that a lesser device, such a standard two wheeled walker or a cane could not address the enrollee's needs. This is a convenience item, and not 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 the Life Glider have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life Glider for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection provided on October 17, 2019 and October 31, 2019.
You asked the Plan to waive the copayment for the facet joint injections. You say that you were informed you owed $0 for the shots. You say that you cannot afford to pay this every month. The Plan denied your request. The Plan says the copayments 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 $395 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center. You have been asked to pay a total of $763.92 for the facet joint injections.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
October 17, 2019
Facet Joint Injection
$381.96
$395
$381.96
October 31, 2019
Facet Joint Injection
$381.96
$395
$381.96
TOTAL:
$763.92
The facet joint injections fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 facet joint injection provided on October 17, 2019 and October 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the irrigation of implanted venous access device for drug delivery systems services provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the irrigation of implanted venous access device for drug delivery systems services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 has network providers available who can provide 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 irrigation of implanted venous access device for drug delivery systems services provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided to the enrollee on July 2, 2019.
You asked the Plan to pay for the surgical assistant services. You say that the provider was requested to assist in the enrollee's surgery. The Plan denied your request. The Plan says surgical assistant services cannot be reimbursed if the assistant is an unlicensed practitioner, or does not qualify to be a Medicare provider.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant services is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided to the enrollee on July 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 and the Hospital discharge day management services coded 99239 provided from October 30, 2019 to November 1, 2019.
You asked the Plan to pay for the subsequent hospital care services and the Hospital discharge day management 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 within the global period.
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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. The CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99233 and 99239 are not supported in the medical record. Specifically, these services were provided within the global period of procedure code 33361 (Transcatheter aortic valve replacement). Procedure code 99233 has an unbundled relationship with procedure code 33361. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services and the Hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 and the Hospital discharge day management services coded 99239 provided from October 30, 2019 to November 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care (99309) provided on October 29, 2019.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.
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 has network providers available who can provide 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 nursing care (99309) provided on October 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this was ordered to rule out mass or splenomegaly. The Plan denied your request. The Plan says although clinical notes were provided, there is no explanation of why this procedure would be beneficial.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found abdominal ultrasound has not been done and since there is concern for possible splenomegaly that assessment should be easily obtained with sonography even in an obese patient such as this one. There is no medical indication for CT of the abdomen absent an ultrasound and since no pelvic symptoms are listed there is no indication for CT of the pelvis. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital services provided from November 25, 2019 through November 29, 2019.
You asked the Plan to waive the copayment for the hospital services. You say that $350 was charged instead of $200. You say that the claim should be processed as observation. 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 $350 copayment each day, day(s) 1-5. Cost-sharing begins on the first day of admission to the hospital. Cost-sharing does not apply to the date of discharge. You have been asked to pay a $700 copayment for the inpatient stay. ($350/day x 2 days = $700). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were admitted as an inpatient on November 27, 2019. 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 hospital services provided from November 25, 2019 through November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory services provided by a non-Medicare certified provider on September 25, 2019.
You asked the Plan to pay for the office visit and laboratory services. You say that you had to get a biopsy due to cancer. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. Review of the file shows that the physician was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit and laboratory services provided by a non-Medicare certified provider on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that it is the facility's responsibility to obtained prior authorization. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that prior authorization was 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 has network providers available who can provide 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 chronic care management provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis services (CPT 20611) provided to the enrollee on November 7, 2018.
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 Current Procedural Terminology (CPT) code 20611 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 20611 is "Arthrocentesis, aspiration and/or injection." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the Description of Procedure states "After sterile preparation of the area, I obtained 5 mL of clear yellowish fluid from the right knee intraarticular space and 3 mL from the left knee intraarticular space. I injected the patient with Monovisc 4 mL intraarticularly into each knee, which she tolerated will without complications." There is no documentation of ultrasound guidance, with permanent recording and reporting. 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 pay for arthrocentesis services (CPT 20611) provided to the enrollee on November 7, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic hereditary predictive screening testing provided on August 5, 2019.
You asked the Plan to pay for the molecular genetic hereditary predictive screening testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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, the molecular genetic hereditary predictive screening testing, 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 molecular genetic hereditary predictive screening testing provided on August 5, 2019.