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

We decided that the Plan does not have to pay foreyelash revision services provided on February 1, 2021.You asked the Plan to pay forthe eyelash revision services. You say that the medical records provided support the services billed.The Plan denied your request. The Plan says the code in dispute has an MUE value of 1 but was billed for 2 units. The Plan says that this number of units exceeds Medicare's rules for payment.The Plan mustfollow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 67830 has an MUE of 1 unit and an MAI of 2. This means that there never can be more than one unit of this code be billed for the same date of service. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the eyelash revision services have not been met.Therefore, we decided that the Plan does not have to pay foreyelash revision services provided on February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factorslisted in the Medicare rules section are met. Custodial care is 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with acute kidney injury, hyperkalemia and rhabdomyolysis. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a supervision/stand by assist to contact guard assist level with functional mobility including gait to 175 feet. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray rendered on March 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 22 for outpatient; however, the enrollee was under inpatient status for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the abdomen x-ray rendered on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), and the prophylaxis (D1110) received February 5, 2021 from the out-of-network provider.You asked the Plan to pay forthe dental services. You say that the Plan should cover these services.The Plan denied your request. The Plan says you do not have coverage for services received out-of-networkMedicare 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 an out-of-network provider. Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), and the prophylaxis (D1110) received February 5, 2021 from the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on October 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99291 is 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care spent on the enrollee. Based on this information, we decided that Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on October 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency care services provided on March 19, 2021.

You asked the Plan to waive the copay for the services provided. You say that you were involuntarily hospitalized. The Plan denied your request. The Plan says the copay applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copay for emergency care.

You have been asked to pay a $90 copay for the services provided. The services fall 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 copay for the emergency care services provided on March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676), provided on October 27, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says items that are used for preventative services or functions are excluded from coverage under the Medicare DME benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676), provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on January 15, 2021.

You asked the Plan to pay for intermittent limb compression device and supplies. You say that the item was medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care represented by code 99232 provided on January 11, 2021.
You asked the Plan to pay for code 99232. 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 covered 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, we have confirmed that code 99232 has a bundled relationship with code 99233 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care represented by code 99232 provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 14, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained inan office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 27, 2019.
You asked the Plan to pay for the services provided. You say that the original claim was sent within the timely filing limit. The Plan denied your request. The Plan says the correct claim was filed past the allowed timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a valid claim for the services was not filed until March 11, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 27, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pay forthe electrocardiogram (ECG) rhythm report provided on November 23, 2020 billed with code 93042-59.You asked the Planto pay forthe ECG rhythm report. You say that the services are separately payable as billed based on the records.The Plandenied your request. The Plansaysthatit is felt that this denial was correct.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 93042 is rhythm ECG, 1-3 leads; interpretation and report only.We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ECG rhythm report. Our reviewers says that the records support this service. Our physician reviewer found an ECG was performed and it was interpreted as sinus tachycardia. As a result, continuous cardiac monitoring was ordered by the physician, and there was a separate interpretation by the rendering provider qualifying 93042-59 to be considered as separate and distinct procedure from the ECG.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 ECG rhythm report have been met.Therefore, we decided that the Planhas to pay forthe electrocardiogram (ECG) rhythm report provided on November 23, 2020 billed with code 93042-59.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a neurology office visit provided on January 27, 2021.

You asked the Plan to waive the co-payment for specialist visit. You say that you cannot pay this amount. The Plan denied your request. The Plan says the co-payment 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 co-payment for specialist visit.

You have been asked to pay $40 co-payment for specialist visit. Specialist 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 co-payment for a neurology office visit provided on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe magnetic resonance imaging (MRI) scan of brain before and after contrast (70553) provided January 21, 2021.You asked the Plan to waive the copayment forthe MRI scan of brain. You say that this copayment is more than you can afford.The Plan denied your request. The Plan says the copayment has processed correctly in this case.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 thePlan clearly says that you must pay a $275 copayment for diagnostic radiology services. You have been asked to pay a $275 copayment for the MRI scan of brain. This service falls within the diagnostic radiology 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 forthe magnetic resonance imaging (MRI) scan of brain before and after contrast (70553) provided January 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on January 11, 2021.
You asked the Plan to pay for the therapeutic activities. You say that medical records were provided. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite and removal of residual tooth roots provided on January 25, 2021 by an OON provider.
You asked the Plan to pay for the resin-based composite and removal of residual tooth roots. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services are only covered by your Health Plan for in-network dentists.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composite and removal of residual tooth roots provided on January 25, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 1, 2021.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Office visits, when provided by a chiropractor, are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transportation (A0425, A0428) received September 1, 2020.You asked the Plan to waive the copayment forthe ambulance transportation. You say that the enrollee was not able to be transported by car after discharge from the hospital and was transported by ambulance to home.The Plan denied your request. The Plan says the correct cost share applied to the claim.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for Ambulance Services. The enrollee has been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transportation (A0425, A0428) received September 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for magnetic resonance imaging (MRI) scan of
blood vessels of leg (73725) provided January 28, 2021.

You asked the Plan to waive the co-payment for the MRI scan of blood vessels of leg. You say that you were
unaware you would be charged a co-payment for this service. The Plan denied your request. The Plan says the
co-payment has processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
co-payment for diagnostic radiology services.

You have been asked to pay a $100 co-payment for the MRI scan of blood vessels of leg. This service falls
within the diagnostic radiology 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 co-payment
for magnetic resonance imaging (MRI) scan of blood vessels of leg (73725) provided January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and segmental gradient pressure pneumatic appliances provided on November 3, 2020.
You asked the Plan to pay for a pneumatic compression device and segmental gradient pressure pneumatic appliances. You say that the durable medical equipment was prescribed by the enrollee's doctor and was issued to the enrollee for use during their surgery. You say that you are not contracted with the facility or the prescribing physician and do not receive payment from either provider. You say that you do not have access to the enrollee's medical records. The Plan denied your request. The Plan says CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. The Plan says that the facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and hospital and outside providers
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. The case file shows that the pneumatic compression device and segmental gradient pressure pneumatic appliances were provided to the enrollee during an inpatient hospital stay. Appliances and equipment provided to the beneficiary during an inpatient stay are included in the payment for the inpatient hospital stay and are not separately payable. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device and segmental gradient pressure pneumatic appliances have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and segmental gradient pressure pneumatic appliances provided on November 3, 2020.