Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on March 8, 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 according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician as required per CMS guideline
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that the denied orthosis codes cannot be verified. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. 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 orthoses (L1833, L2397) provided to the enrollee on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laparoscopy, surgical; cholecystectomy (CPT code 47562) and laparoscopy, surgical; cholecystectomy with cholangiography (CPT code 47563) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the surgery. You say that you have made arrangements for your family to be in town to assist. You state you were not given the opportunity to seek an in-network surgeon. You state you need this surgery as soon as possible. The Plan denied your request. The Plan says the surgery is not urgent or emergent and is able to be performed by an in-network provider and in a contracted facility within your service area.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 surgery. Our physician reviewer found the records indicate that you were evaluated as an outpatient for symptomatic cholelithiasis. You are scheduled for an outpatient laparoscopic cholecystectomy. The prior authorization form lists continuity of care as the reason for the out-of-network request. The plan has indicated that it has in-network surgeons capable of performing the operation. This is a discrete care episode. The records provided do not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. 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 surgery have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the surgery. Therefore, we decided that the Plan does not have to pre-approve the laparoscopy, surgical; cholecystectomy (CPT code 47562) and laparoscopy, surgical; cholecystectomy with cholangiography (CPT code 47563) to be performed by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a total knee arthroplasty (27447) provided on October 7, 2020.

You asked the Plan to pay for surgical assistant services. You say that this is supported in the records. The Plan denied your request. The Plan says the records show the service at issue was not provided by an eligible 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 service 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 surgical assistant services on a total knee arthroplasty (27447) provided on October 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response without transport provided on February 4, 2021.
You asked the Plan to pay for the ambulance response without transport. You say that you feel that this should be covered because you did not refuse transport but were told you did not need to go to the hospital. You do not feel you should have to pay for the ambulance response since they did not transport you. The Plan denied your request. The Plan says this is not a Medicare-covered service.
The Plan follows Medicare rules. Medicare rules say that ambulance services are only covered when the enrollee is transported. The COVID waiver allows for coverage of ambulance response without transport only in instances where transport would have been reasonable but did not occur due to COVID EMS protocols. 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 ambulance response without transport. Our reviewer says that the documentation does not support that ambulance transportation would have been medically necessary as required under the COVID waiver. Our physician reviewer found the enrollee was experiencing chest pain, and EMS was called. They arrived to find the patient siting in chair, alert and oriented. He was dizzy and weak at the time, but the pain had passed and was breathing easier now. He did still have palpitations, but vitals were normal. There was a known history of atrial fibrillation with use of warfarin. The EMS and patient decided that he would instead follow-up with his primary care physician that same day rather than go to the hospital as the EMS did not feel hospital care was needed. As such, the coverage rules under the waiver are not met. 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 ambulance response without transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance response without transport provided on February 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on March 28, 2021.
You asked the Plan to pay for the emergency department visit. You say that you feel this claim should be paid. The Plan denied your request. The Plan says the services are not payable as 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 find that CPT code 99285 is not supported in the medical record. Specifically, this code was not billed with the appropriate primary, first-listed diagnosis. The claim was billed with a primary diagnosis code of T50.905A (Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter). This diagnosis code is a secondary only diagnosis. A secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service. 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 coded 99285 provided on March 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and chiropractic manipulative treatment provided on July 29, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and chiropractic manipulative treatment. 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 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 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 chiropractic manipulative treatment provided on July 29, 2020 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital clinic visit provided
on March 3, 2021.
You asked the Plan to waive the copayment for clinic visit. You say that you want to appeal this charge. The
Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $475
copayment for clinic visit.
You have been asked to pay the allowed amount of $128.35, which is less than the $475 copayment for clinic
visit. Clinic visit falls within the Outpatient Hospital Services 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 an outpatient hospital clinic visit provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on June 29, 2020.
You asked the Plan to pay for the initial hospital care. 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 initial hospital care. Our reviewer says that CPT code 99223 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that an initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit was performed on June 29, 2020. 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 initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the fillings for teeth # 21, 22, 23, and 24 provided on April 5, 2021.

You asked the Plan to pay more for the dental services. You say that you are trying to take care of the teeth that you have left. You also say that you would like these services to be covered. The Plan denied your request. The Plan says there is a maximum allowance of $1,000 for covered dental services. The Plan also says that the maximum allowance has been exhausted.

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 maximum allowance has been exhausted.

The Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay more for the fillings for teeth # 21, 22, 23, and 24 provided on April 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided March 11, 2021.
You asked the Plan to waive the copayment for the emergency visit. You say that you are appealing the charges for the emergency room visit. You feel the charges should all be a part of the emergency room costs and no copay should apply. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $90 copayment for each emergency room visit. You have been asked to pay $90 copayment for the emergency visit. The emergency visit falls within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (CPT code 99203) provided on March 4, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you were not treated, and you were turned away. The Plan denied your request. The Plan says they confirmed with the doctor's office that you were seen for this date of service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received you were seen on March 4, 2021, to establish care for diabetic foot issues. You were asked to pay a $40 copayment for the specialist office visit. Your 2021 EOC states that enrollees must pay a $40 copayment for each specialist 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 (CPT code 99203) provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pharmacogenetic testing provided on July 15, 2020.
You asked the Plan to pay for the molecular pharmacogenetic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says if a laboratory produces multiple reportable test results, only a single CPT code shall be reported for the procedure.
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 pharmacogenetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include and laboratory results or clinical information to determine why this testing was ordered. Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing provided on July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the computer-assisted surgical navigational procedure (20985) provided on December 7, 2020.
You asked the Plan to pay for the computer-assisted surgical navigational procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 20985 is not separately reimbursable.
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 computer-assisted surgical navigational procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the role of computer-assisted surgical navigational procedure for total hip arthroplasty has not been adequately established in the medical literature. It has not been adequately demonstrated that this procedure improves patient outcomes. 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 computer-assisted surgical navigational procedure have not been met. Therefore, we decided that the Plan does not have to pay for the computer-assisted surgical navigational procedure (20985) provided on December 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of a hip fracture and non-operative management of a wrist fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (CPT 99601 and CPT 99602) provided to the enrollee on July 31, 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 this is an invalid procedure code 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 99601 and 99602 is not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion services (CPT 99601 and CPT 99602) provided to the enrollee on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at the in-network rate the office or other outpatient visit (99214) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve at the in-network rate the office or other outpatient visit. You say that care with an OON provider is medically necessary. The Plan denied your request. The Plan says they have in-network providers available for treatment.
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 pre-approve at the in-network rate the care from out-of-network providers only in cases where an in-network provider is not available to provide the care you need. 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. We found no exception that would require the Plan to pre-approve at the in-network rate the these items/services. Therefore, we decided that the Plan does not have to pre-approve at the in-network rate the office or other outpatient visit (99214) to be provided by an out-of-network (OON) provider.