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

We decided that the Plan does not have to pay for the inpatient hospital services rendered from June 20, 2020,
to June 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 the submitted records do not support the billed DRG and diagnosis code.

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 689 and diagnosis code G92 (toxic
encephalopathy). 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 these services. Our
reviewer says that the submitted records do not support the billed DRG and diagnosis code. Our physician
reviewer found the records indicate acute toxic metabolic encephalopathy (TME), which encompasses delirium
and the acute confusional state, is an acute condition of global cerebral dysfunction in the absence of primary
structural brain disease. The diagnosis must be supported by findings reported on physical examination. In this
case, the enrollee was noted to be at baseline mental status on presentation to the emergency room. There was
no significant alteration in mental status beyond the enrollee's baseline at the time of admission or during the
course of the hospitalization, which justified the coding of encephalopathy. The records do not support the
billing of DRG 689 and diagnosis code G92 (toxic encephalopathy).

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
for the inpatient hospital services rendered from June 20, 2020, to June 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services represented by codes 15002 and 15275 provided August 25, 2020.
You asked the Plan to pay for the surgical services represented by codes 15002 and 15275. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the medical records do not support the codes 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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.
The CPT code Manual definition of code15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 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 surgical services represented by codes 15002 and 15275. Our reviewer says that the record does not support the codes billed in this case. Our physician reviewer found that the medical records provided do not include sufficient documentation to validate that a surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children was performed on August 25, 2020, therefore this service cannot be verified. In addition, the medical records provided do not include sufficient documentation to validate that an application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area was performed on August 25, 2020. 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 surgical services represented by codes 15002 and 15275 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services represented by codes 15002 and 15275 provided August 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 4, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 December 4, 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 December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection provided on March 24, 2021.
You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you are paying your $40 copayment and you are being overcharged. You say that the Plan should be paying. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for the total cost of Part B drugs purchased at a pharmacy, administered by a pharmacist, or administered by a health care professional.
You have been asked to pay $106.27, which is 20% of the allowed amount for the Synvisc injection. The allowed amount is $531.36 (20% x $531.36 = $106.27). The Synvisc injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Synvisc injection provided on March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge day management, more than 30 minutes, (99316) provided on January 30, 2020.

You asked the Plan to pay for the evaluation and management service. You say that you did not receive proper notice of the enrollee's benefit determination. You say that as a result, the claim was submitted untimely. You also say that you depend on the facility for timely notification of the enrollee's health insurance coverage. The Plan denied your request. The Plan says the claim was submitted more than 12 months after the date of service in this case. The Plan also says that claims filed more than 12 months after the date of service are not payable.

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 claim for the evaluation and management service was not filed until February 8, 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 nursing facility discharge day management, more than 30 minutes, (99316) provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on August 17, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression
or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is
application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The
HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals).
The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection
(specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code
J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection,
thiamine HCl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine HCl,
100 mg. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm.
We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record.
Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer
of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the
criteria to report CPT code 97016.
The record also does not support that manual electrical stimulation was applied to any area for any amount of
time. The record states that the Sanexas device was applied using standard programs. This does not support
constant direct patient contact, which is required to report CPT code 97032.
The record also does not support that therapeutic procedures in a group of 2 or more was performed. The
record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at
the same time; the criteria for reporting CPT code 97150 has not been met.
Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record
does not contain documentation of the dosage and type of drug administered in each injection, which is
required by Medicare for these services to be reimbursed.
Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections
and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to
pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), removal of torus mandibularis (D7473), bone replacement grafts for ridge preservation -per site (D7953), and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 23, 2019.You asked the Plan to pay forthe extractions, removal of torus mandibularis and bone replacement grafts. You say that the Plan covered the same services for your upper jaw in 2016 and you do not understand why the Plan will not cover the services for the lower jaw now.The Plan denied your request. The Plan says these services are not covered under your 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 the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), removal of torus mandibularis (D7473), bone replacement grafts for ridge preservation -per site (D7953), and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 23, 2019.Your complaint about potential changes in benefits or coverage since 2016 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 27, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that all specialist visits should be fully covered with no copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $10 copayment for specialist visits. You have been asked to pay a $10 copayment for a specialist visit. A 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 copayment for a specialist visit provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to apply the out-of-network coverage rate to the vertical bitewings provided on February 2, 2021 by an OON provider.
You asked the Plan to pay for the bitewings. You say that you believe 50% of this service should be covered because it is listed as a covered service, and was provided OON. The Plan denied your request. The Plan says that this service is not covered.
Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. This service was denied by the Plan as not being covered. The EOC states that bitewing x-rays are covered, and does not specify exactly which type of bitewing x-rays are covered. You reasonably believed the vertical bitewings would be covered, because bitewing x-rays are listed as a covered service. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bitewings have been met. Therefore, we decided that the Plan has to apply the out-of-network coverage rate to the vertical bitewings provided on February 2, 2021 by an OON provider.
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 office visit provided on October 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the corrected claims reprocessed. You say the service was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin surgical procedure provided on
February 13, 2021.
You asked the Plan to waive the copayment for the skin surgical procedures. You say that you should not be
responsible for this copayment. The Plan denied your request. The Plan says you have been asked to pay the
correct cost-sharing amount.
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 $50
copayment per visit for a specialist office visit.
You have been asked to pay a $50 copayment for the skin surgical procedure. The skin surgical procedure falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical
record shows a Mohs microscopic surgery was performed.
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 skin surgical procedure provided on February 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for administration of chemotherapy on December 7, December 14, and December 21, 2020.

You asked the Plan to waive the coinsurance for administration of chemotherapy. You say that you do not owe the charge at issue as you have met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 20% coinsurance for chemotherapy drugs.

In this case, the Plan has documented that you had not reached your out-of-pocket maximum for the 2020
calendar year. The contract states that amounts you pay for your Part D prescription drugs, and services from
out-of-network providers do not count toward your in-network maximum out-of-pocket amount. In addition,
amounts you pay for some services, marked with an asterisk in the contract, do not count toward your in-network
maximum out-of-pocket amount.

Therefore, you have been asked to pay a total of $1,003.08, or 20% of the Medicare-allowed amount of
$5,015.42, for administration of chemotherapy. Administration of chemotherapy falls within the "Medicare
Part B prescription drugs" 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 coinsurance for
administration of chemotherapy on December 7, December 14, and December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy of the right leg anterior thigh circumflex vein (36478) and left leg Sclerotherapy and Phlebectomy (37765).
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. 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 these services. Our reviewer says that these services are not medically necessary. Our physician reviewer found that in this case, the enrollee is symptomatic. The medical record documentation submitted indicates that there is reflux in the right saphenofemoral junction and left greater saphenous vein that have not been treated. The elements of the coverage rule are not satisfied. The requested services cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy of the right leg anterior thigh circumflex vein (36478) and left leg Sclerotherapy and Phlebectomy (37765).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215} routine electrocardiogram (ECG) with at least 12 leads (93000) provided on November 13, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you have attached the claim form along with medical records for review. Please reconsider this claim for possible reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 office visit (99215} routine electrocardiogram (ECG) with at least 12 leads (93000) provided on November 13, 2020 by an out of network (OON) provider.