Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for skin substitute graft services (CPT 15271, CPT 15272) provided to the enrollee on October 7, 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 that the denied codes remain 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 the denied codes is:

CPT 15271: 

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area

CPT 15272: 

Each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

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 supported by the medical records. Our physician reviewer found in this case, the record indicates that the total area covered was approximately 35 cm2. The record indicates that provider chose to secure the graft with layered dressing. The elements of the CPT codes have been satisfied.

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 for skin substitute graft services (CPT 15271, CPT 15272) provided to the enrollee on October 7, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided from April 9, 2020, to April 11, 2020.

You asked the Plan to pay for radiology services. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan is not responsible for payment of services until the first day of the month following the revocation of or discharge from hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on April 9, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for radiology services provided from April 9, 2020, to April 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted gene panel provided on December 15, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says targeted next generation sequencing panel should use CPT code 81479.

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 looked at the file and the rules. If no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with one unit of service. 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 targeted gene panel provided on December 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 29, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the provider should have verified the member's eligibility, health benefits and obtained authorization prior to the member's visit before providing services to the member as outlined on the member's ID card.

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 physical therapy visits. 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 physical therapy services provided on June 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 22, 2020.

You asked the Plan to pay for the ambulance services. You say that your father was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

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 August 22, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342), and scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346).

You asked the Plan to pay for the periodontal scaling and root planing and scaling in presence of generalized moderate or severe gingival inflammation. You say that you were not informed that the requested services would not be covered by the plan. The Plan denied your request. The Plan says the requested services are not covered or exceed the coverage offered by your plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit or exceed coverage offered by the Plan. The Plan does not cover scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346). The requested payment for the periodontal scaling and root planing (D4342) is in excess of the Plan's coverage. The Plan agreed to pay 100% of the allowed amount of $72 for the requested service. You are responsible for the difference between what the provider charged and the Plan's allowed amount ($168 - $72 = $96). Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342), and scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of May 6, 2021 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors. He was being cooperative and compliant as well with activities of daily living (ADLs).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Tenotomy, shoulder area and Arthroscopy, shoulder provided on January 8, 2020.

You asked the Plan to pay for Tenotomy, shoulder area; single tendon (23405), Arthroscopy, shoulder, surgical; repair of SLAP lesion (29807). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Tenotomy procedure was not documented in the operate report narrative and the arthroscopy is not valid for assistant at surgery services.

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 Tenotomy, shoulder area; single tendon (23405). Our reviewer says that Tenotomy, shoulder area, single tendon (23405) was not performed. Our physician reviewer found the documentation does not support that Tenotomy, shoulder area, single tendon (23405) was performed.

We looked at this physician's review, the file, and Medicare rules. The documentation does not support the Tenotomy was performed. The code 29807 has an assigned Assistant Surgery Indicator of 1 which is not valid for assistant at surgery services. Based on this information, we decided that Medicare rules for coverage of Tenotomy, shoulder area; single tendon (23405), Arthroscopy, shoulder, surgical; repair of SLAP lesion (29807) have not been met. Therefore, we decided that the Plan does not have to pay for Tenotomy, shoulder area and Arthroscopy, shoulder provided on January 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on January 13, 2021.

You asked the Plan to waive the copayment for the endoscopy. You say that you were not aware of the copayment and cannot afford to pay. 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 $200 copayment per visit for outpatient surgery at ambulatory surgical centers. 

You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including 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 endoscopy provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IV feedings with fats.

You asked the Plan to pre-approve the IV feeding. You say that you would like reconsideration because the member does not have adequate nutrition to meet 100% of needs. The Plan denied your request. The Plan says there is no documentation of inability to take oral food and liquids and no documentation of inability of the gastrointestinal tract to adequately absorb good and liquid nutrients.

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 IV feeding. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested IV feedings. There is no documentation of any inability to take oral food and liquids. There is no documentation of GI tract inability to absorb food and liquid nutrition. 

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 IV feeding have not been met. Therefore, we decided that the Plan does not have to pre-approve IV feedings with fats.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose monitor and accessories provided on June 19, 2020 to September 18, 2020.

You asked the Plan to pay for the blood glucose monitor and accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items provided are not supported by the documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order for the supplies provided in this case. The documentation submitted did include a physician's order that indicates the billed services were performed by a health care provider other than the billing health care provider for the billed date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the blood glucose monitor and accessories provided on June 19, 2020 to September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transportation trips.

You asked the Plan to approve these services. You say that you are on disability and need more rides. The Plan denied your request. The Plan says you have exhausted the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health visits received
from August 26, 2020, to January 12, 2021.
You asked the Plan to waive the copayments for the visits. You say that you were not told that there would be a
charge. The Plan denied your request. The Plan says the copayment was applied correctly according to your
benefits and the services rendered.
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 $40
copayment for outpatient mental health care.
You have been asked to pay a $40 copayment for each of the visits. The visits fall within the outpatient mental
health 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 copayments for outpatient mental health
visits received from August 26, 2020, to January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
January 18, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the Plan applied the full eyewear benefit allowance to the claim.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan applied the full eyewear benefit to the claim. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for hospital services (99233, 90460, 99232 and 99239) provided on April
13, 2020, through April 15, 2020.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that additional information is needed in order
to process this claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has failed to forward any information regarding why this
claim was billed incorrectly. It is the burden of the Health Plan to substantiate their denial with evidence. This
denial has not been substantiated; therefore, we must find in your favor Therefore, we decided that the Plan has
to pay for hospital services (99233, 90460, 99232 and 99239) provided on April 13, 2020, through April 15,
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided November 13, 2020.

You asked the Plan to pay for a continuous glucose monitor. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim processed correctly and no payment is due.

The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment provider is not allowed to contact an enrollee through an unsolicited phone call.

We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided November 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require services at the LTACH that are not available at the acute care hospital. The clinical assessment in the case file does not support that you are reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 29, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a device evaluation (93284) provided on August 7, 2020
You asked the Plan to pay for a device evaluation. You say that this should be covered. The Plan denied your
request. The Plan says this was not billed with a required modifier.
The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to
suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay.
We looked at the file and Medicare rules. The service at issue has both a professional and technical component.
The record shows that it was provided to a beneficiary in an inpatient stay, meaning the technical component is
not payable, but it was not billed with a modifier to indicate only the professional component is being billed.
Based on this information, we decided that Medicare rules for coverage of a device evaluation have not been
met. Therefore, we decided that the Plan does not have to pay for a device evaluation (93284) provided on
August 7, 2020.