Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient services provided from August 15, 2019, to August 16, 2019, and billed with diagnosis related group (DRG) 853.You asked the Plan to pay forinpatient services. You say that this was billed with the correct DRG.The Plan denied your request. The Plan says the records support DRG 871 rather than 853.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  In this case, you billed the inpatient services provided with DRG, 853 infectious and parasitic diseases with operating room procedure and major complications or comorbidities. 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 inpatient services. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the submitted records show that the enrollee's diagnoses included septic shock, Bacteroides fragilis bacteremia, necrotic pelvic mass, acute hypoxic respiratory failure secondary to pneumonia, and acute kidney injury. While the enrollee was found to have a pelvic mass that was necrotic and concerning for malignancy, there was no documentation found within the consultation that indicated intent to perform a procedure. A bimanual examination was being performed at which time pieces of the mass became dislodged. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed.Therefore, we decided that the Plan does not have to pay forinpatient services provided from August 15, 2019, to August 16, 2019, and billed with diagnosis related group (DRG) 853.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forelectrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on January 1, 2021.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says that the medical records do not support this service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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 forthe services. Our physician reviewer found the reviewed documentation indicates that the medical records that were submitted were not missing supporting documentation for CPT 93010 ECG for date of service January 1, 2021. The EKG is included with interpretation in the note along with history/physical/lab studies and CXR. The review has determined that the medical records provided did support the services the enrollee received.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 been met.Therefore, we decided that the Plan has to pay forelectrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010) provided to the enrollee on January 1, 2021.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for laboratory services provided on September 9, 2020.

You asked the Plan to pay for the laboratory services. You say that you have no other insurance. The Plan denied your request. The Plan says that the enrollee had other insurance on the date of service in dispute.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not shown that they sent the bill directly to the primary insurer, directed the provider to send the bill to the primary insurer, or paid for the services and submitted a bill for reimbursement to the primary insurer. The Plan has not made reasonable and diligent efforts to gather and forward us information that supports their having met their obligation in regard to coordination of benefits. Therefore, we decided that the Plan has to pay for laboratory services provided on September 9, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone audio-only consultation provided on December 29, 2020 billed with code 99214-UD.

You asked the Plan to pay for the audio-only telephone consult. You say that this is correct billing with this modifier and place of service code for Arizona Medicaid. The Plan denied your request. The Plan says the incorrect POS code was used for this claim.

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 99214-UD is not supported in the medical record. Specifically, Medicare has established specific codes to report audio-only telephone consultations, 99441, 99442, and 99443.

The use of modifier -UD to report a telephone consultation is not recognized in Medicare billing rules. Based
on this information, we decided that Medicare rules for coverage of the audio-only telephone consult have not
been met. Therefore, we decided that the Plan does not have to pay for the telephone audio-only consultation
provided on December 29, 2020 billed with code 99214-UD.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a percutaneous peripheral nerve stimulator.

You asked the Plan to pre-approve percutaneous peripheral nerve stimulator. You say that this is not being used to assess the enrollee's suitability for a permanent implant and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Medicare does not cover a percutaneous nerve stimulator as a destination therapy and is only intended as a bridge to implantation of a permanent device.

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 percutaneous peripheral nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a percutaneous peripheral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and lesion removal provided by an out-of-network provider on October 26, 2020.You asked the Plan to pay forthe office visit and lesion removal. The Plan denied your request. The Plan says prior authorization was required but not obtained. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan hasto pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay forthe office visit and lesion removal provided by an out-of-network provider on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) received January 18, 2021 from the Medicare opt-out provider.

You asked the Plan to pay for the periodontal maintenance. You say that the Plan should pay for the requested services. The Plan denied your request. The Plan says the provider in this case does not accept payment from Medicare.

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 under this benefit when received from a provider who has opted out of Original Medicare. We have confirmed that the provider in this case opted out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) received January 18, 2021 from the Medicare
opt-out provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe surgical placement of implant body: endosteal implant provided on October 20, 2020.You asked the Plan to pay forthe endosteal implant. You say that you have paid extra for dental insurance, and would like this service to be covered.The Plan denied your request. The Plan says that non-covered charges were applied to your liability.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. Medicare rules say that for services paid on a fee schedule, Medicare secondary payment amounts are determined by a formula and are the lowest of: Excess of the actual charge minus the primary payment; The amount Medicare would pay if the services were not covered by a primary payer; or The higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer.We looked at the file and Medicare rules. The documentation shows that there was a primary payer who paid $500 toward the $1,250 charge for the implant. Thismeans that the enrollee remains liable for $750 for the implant. The Plan's Explanation of Benefits shows that the allowed amount for the endosteal implant is $947.63, and the EOC says that the Plan is to pay a 50% coinsurance. This means that the amount that the Plan would pay if there were no primary payer is $473.82. As this is the lowest of the amounts determined by the secondary payer formula, this is the amount that the Plan is obligated to pay in this case.Based on this information, we decided thatthe Plan's rules for coverage of the endosteal implant have been met.Therefore, we decided that the Plan has to pay forthe surgical placement of implant body: endosteal implant provided on October 20, 2020. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on September 30, 2020.
You asked the Plan to pay for the services provided. You say that the documentation supports the level of treatment billed. The Plan denied your request. The Plan says the appropriate place of treatment is not billed correctly. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. Services submitted for payment in a manner not complete and consistent according to these instructions will not be accepted. The records show that the Plan has requested a corrected claim in order to reprocess for payment. 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 wound care services provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the evaluation of wheezing (94060)
provided on January 26, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $25
copayment for diagnostic tests and procedures. You have been asked to pay a $25 copayment for the diagnostic test provided. 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 evaluation of wheezing (94060) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids (V5050) purchased on December 17, 2020.You asked the Plan to pay forthe hearing aids. You say that your primary insurance does not cover hearing aids, and you are requesting reimbursement from the Plan because they offer a hearing aid benefit.The Plan denied your request. The Plan says while they can cover out-of-network services, generally these services must be pre-approved by the Plan. You did not request prior authorization for the hearing aids purchased from an out-of-network provider, and these items could have been provided in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that services provided out-of-network must be pre-approved in order to be covered. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. The Plan pays for hearing aids purchased out-of-network only when they are pre-approved. We looked at the file and the Plan's rules. 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 hearing aids were not pre-approved for purchase out-of-network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay forthe hearing aids (V5050) purchased on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and laboratory test provided by an out-of-network provider on January 9, 2020.You asked the Plan to pay forthe office visit and laboratory test. You say that you are appealing the claim with medical records for further processing.The Plan denied your request. The Plan says services from out-of-network providers are not covered unless preauthorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit and laboratory test provided by an out-of-network provider on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance response and treatment without transport (A0998) provided on September 1, 2020.You asked the Plan to pay forthe ambulance response and treatment without transport. You say that you would like reconsideration because you passed out in your home and your husband called 911 for medical assistance. You also say that the emergency medical technicians responded within minutes and determined that you did not need to go to the hospital.The Plan denied your request. The Plan says because there was no transport, the ambulance charges are not covered.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 September 1, 2020. The ambulance benefit is a transportation benefit. Whenthere is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance response and treatment without transport (A0998) provided on September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance service, basic life support, emergency transport (A0429, A0425) provided on February 20, 2021.You asked the Plan to pay forambulance service, basic life support, emergency transport (A0429, A0425). You say that the ambulance transport was medically necessary.The Plan denied your request. The Plan says the ambulance transport was not medically necessary.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, emergency transport(A0429, A0425). Our reviewer says that the ambulance transport was not medically reasonable or necessary.Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The enrollee was stable and had no emergency according to the notes.The documentation does not support that other means oftransport were contraindicated. The documentation does not support that the enrollee needed expertise and special equipment during transport.The ambulance transport was not medically reasonable or necessary for the enrollee according to the records provided.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, emergency transport(A0429, A0425) have not been met.Therefore, we decided that the Plan does not have to pay forambulance service, basic life support, emergency transport (A0429, A0425) provided on February 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe x-ray provided on April 8, 2021.You asked the Plan to waive the deductible forthe x-ray. You say that you were charged for a hand x-ray when it should have been a finger x-ray. You say that you should not have to pay for this.The Plan denied your request. The Plan says the deductible applied correctly.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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for 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 your $750 deductible applies to basic imaging services. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on April 8, 2021.The records show a hand x-ray was performed. Therefore, we decided that the Plan does not have to waive the deductible forthe x-ray provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 25, 2021.

You asked the Plan to pay for the home visit. You say that the patient did not have many options to pick another provider to make a home visit in a skilled nursing facility. You say that the medical records support the medical necessity, and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities represented by code 97530 provided on September 11, 2020.
You asked the Plan to pay for code 97530. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.
We find that 3 units of CPT code 97530 are not supported in the medical record. The medical record only supports 2 units of CPT code 97530. Based on this information, we decided that Medicare rules for coverage of code 97530 have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities represented by code 97530 provided on September 11, 2020.