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

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003 and U0005) provided on January 26, 2021.
You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be reprocessed for payment. 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 enrollee's terminal condition. 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 the infectious agent detection by nucleic acid (U0003 and U0005) provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on April 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 specialist services provided on April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 16, 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 procedure code 29826 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 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).

We find that CPT code 29826 is not supported in the medical record. Specifically, the operative report does not contain documentation of a surgical shoulder arthroscopy with decompression of subacromial space. 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 surgical services rendered on March 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 18, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are being billed directly for this service and would like the Plan to pay for this bill. The Plan denied your request. The Plan says this service is not covered by Medicare.

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 March 18, 2021. 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 response and treatment with no transport (A0998) provided on March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance services provided on March 8, 2021.

You asked the Plan to pay for the services provided. You say that the procedure requires accuracy to avoid misplacement of the needle. The Plan denied your request. The Plan says no eligible base code has been 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 77002 is fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure).

We looked at the file and the rules. We find that CPT code 77002 was not billed with a valid primary procedure code. 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 fluoroscopic guidance services provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services (S1015, S8301, 99199) provided to the enrollee on December 17, 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 these are invalid procedure codes 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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. Additionally, CPT 991999 should not be billed by an anesthesia practitioner. 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 practitioner services (S1015, S8301, 99199) provided to the enrollee on December 17, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided to the enrollee on December 21, 2020.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says that this was an administrative denial based on a coding error. The Plan is basing their decision on the Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624), the Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer (A55197), and the Medicare Local Coverage Article (A57936): Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors.

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 Plans are expected to use Medicare regulations that have a MAC B jurisdiction designation for either the state the enrollee lives in or the state in which the provider is located. The enrollee lives in Utah and the Provider is in Illinois. The regulations referenced by the Plan do not show MAC B jurisdiction for Utah or Illinois and therefore do not apply. This means, the Plan has not substantiated its denial as the appropriate Medicare regulations were not used to determined coverage or coding guidelines. Therefore, we decided that the Plan has to pay for genetic testing provided to the enrollee on December 21, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on December 22, 2020.

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim denied correctly for needing third party information from the member.

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 met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan has directed to provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (22612, 22214, 27280, 22843, 22614, 22216, 61783) provided on February 11, 2021.

You asked the Plan to pay for surgical services. You say that these services were billed correctly. The Plan denied your request. The Plan says these codes are 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. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT codes 22612, 22214, 27280, 22843, 22614, 22216, and 61783 are not supported in the medical record. Specifically, no medical records documenting these services have been submitted. Based on this information, we decided that Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (22612, 22214, 27280, 22843, 22614, 22216, 61783) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on October 21, 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 99152 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 99152 is Moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 

We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status, for the first 15 minutes. 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 moderate sedation services rendered on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on March 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the device is a covered benefit and does not require prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The file shows that the enrollee received a transcutaneous electrical nerve stimulation (TENS) device. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for durable medical equipment provided on March 8, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital clinic visit, and laboratory work provided on September 14, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient hospital clinic visit and the laboratory work. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient hospital clinic visit, and laboratory
work provided on September 14, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 18, 2021.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 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, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 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 88341 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 88341 is Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). 

We find that CPT code 88341 is not supported in the medical record. Specifically, this is an add-on code and the documentation shows a valid primary procedure code was not billed. 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 laboratory services rendered on November 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on May 4, 2021 and May 5, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were an inpatient and were never provided drugs to self-administer. You say that the charges should be reconsidered. The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs. Self-administered drugs may be covered under your Part D Prescription Drug benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on May 4, 2021 and May 5, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient mental health admission from August 18, 2021, onward.
You asked the Plan to pre-approve ongoing inpatient services. You say that continued care is necessary for this enrollee, as there is no longer a place for them at their previous nursing home facility and they have nowhere to go and no family who can care for them. The Plan denied your request. The Plan says they have agreed to cover the inpatient psychiatric admission and care from August 6, 2021, to August 17, 2021, but argues that they are unable to find medical necessity to continue care at the inpatient level from August 18, 2021, onward.
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 ongoing inpatient services. Our reviewer says that the Plan's denial of ongoing inpatient mental health services is appropriate in this case. Our physician reviewer found this enrollee does not require ongoing acute inpatient psychiatric care. They can be transferred to either a step-down unit or another rehab facility until long-term nursing home care becomes available. The request for ongoing acute inpatient psychiatric care is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ongoing inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient mental health admission from August 18, 2021, onward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography capture and interpretation (D0364), incomplete endodontic therapy (D3332), and an unspecified preventive procedure (D1999) provided on March 30, 2021.
You asked the Plan to pay for a cone beam computed tomography capture and interpretation, incomplete endodontic therapy, and an unspecified preventive procedure. You say that you want the Plan to pay for a portion of the services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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. Therefore, we decided that the Plan does not have to pay for a cone beam computed tomography capture and interpretation (D0364), incomplete endodontic therapy (D3332), and an unspecified preventive procedure (D1999) provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a quantity exception on diabetic test strips for the enrollee.

You asked the Plan to pre-approve the exception. You say that this is medically necessary. The Plan denied your request. The Plan says that information from the provider showing medical criteria for approval of a quantity exception for test strips was not received.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the exception. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is on a regimen for his diagnosis that should not cause low blood sugars. He is on Trulicity, Jardiance, and Metformin; hence, checking one time a day should suffice. One time a day would require 90 strips for 90 days, which is more than the approved 50 for 90 days. 

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 exception have been met. Therefore, we decided that the Plan has to pre-approve a quantity exception on diabetic test strips for the enrollee.

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.