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

We decided that the Plan does not have to pay for the surgical 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 codes 15004, 14301, 14302, and 14060 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. In this case, the CPT Code Manual definition of code 15004 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, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. The definition of code 14301 is adjacent tissue transfer or
rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue
transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to
code for primary procedure). The definition of code 14060 is adjacent tissue transfer or rearrangement, eyelids,
nose, ears and/or lips; defect 10 sq cm or less.
We find that CPT codes 15004, 14301, 14302, and 14060 are not supported in the medical record. Specifically,
there is no documentation of surgical preparation or creation of recipient site by excision of open wounds for
the first 100 sq cm to support code 15004. There is no documentation of an adjacent tissue transfer or
arrangement of any area for defects 30.1 sq cm to 60.0 sq cm to support code 14301. Given that primary code
14301 is not supported, add-on code 14302 is also not supported. There is no documentation of adjacent tissue
transfer or rearrangement of a defect of the eyelids, nose, ears, and/or lips of 10 sq cm or less to support code
14060.
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 November 17,
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), allergy test (95004), and the Federally qualified health center visit (G0466) rendered by the out-of-network (OON) provider on November 23, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the office visit (99203), allergy test (95004), and the Federally qualified health center visit (G0466) rendered by the out-of-network (OON) provider on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on April 26, 2021.
You asked the Plan to waive the copayment for arthrocentesis. You say that you feel that you should owe much
less. 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 $295
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
Your received arthrocentesis at an outpatient hospital facility on April 26, 2021. Arthrocentesis is considered
an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $254.27, which
is less than the $295 copayment.
You have been asked to pay the total copayment amount of $254.27 for arthrocentesis. Arthrocentesis 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 arthrocentesis provided on
April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 14, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that it is felt that an acute rehabilitation program would benefit the enrollee's level of function. The Plan denied your request. The Plan says the IRF criteria have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for COVID pneumonia and dehydration and was discharged home on 8/11/21 with home health services. He has ongoing weakness and has fallen. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (99217) provided January 20, 2021.
You asked the Plan to pay for the observation services. You say that this enrollee went into the emergency room and was seen by the emergency room physician for a medically necessary procedure. Please reprocess this claim and pay this procedure code. The Plan denied your request. The Plan says this service is bundled to another service billed on the same claim. Procedure code is incidental to a primary procedure.
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 the observation services has a bundled relationship with code 99220 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 observation care discharge day management (99217) provided January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 3, 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 29828 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 29828 is arthroscopy, shoulder, surgical; biceps tenodesis. We find that CPT code 29828 is not supported in the medical record. Specifically, there is no documentation of a surgical shoulder arthroscopic biceps tenodesis. 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 December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 15, 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 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 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 September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pre-approve a core buildup, including any pins when required (D2950).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not tried all of the preferred medicines.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our physician reviewer found that the enrollee has osteoarthritis of the knee. The Plan requires a trial of Synvisc, Durolane, and Gelsyn-3 before they will approve the requested drug. The records do not clearly show that the enrollee had tried and failed the required drugs. The preferred drugs are in the same drug category as Euflexxa and would be therapeutically equivalent with no significant difference in benefit or safety making the preferred drug options reasonable for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an intensive rehabilitation team in order to receive services.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our physician reviewer found that you were admitted to the acute care hospital for metabolic encephalopathy and pressure ulcerations of sacrum. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on
February 3, 2021.
You asked the Plan to pay for this claim. You say that this equipment was provided for use during and after
surgery and should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing
criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers.
This equipment was used during and after a surgical procedure by the facility. Payment for this service would
have been included under the facility claim. Payment to you for this service is the responsibility of the facility
or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
provided to the enrollee on February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital observation services you received on November 4, 2020, to November 5, 2020.

You asked the Plan to waive the copayment for the hospital observation services. You say that this claim should be paid in full. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment for hospital observation services. 

You have been asked to pay a $300 copayment for the hospital observation services. 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 hospital observation services you received on November 4, 2020, to November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).

You asked the Plan to pre-approve a continuous glucose monitor. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. 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 pre-approve a continuous glucose monitor (K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray you had on March 23, 2021.

You asked the Plan to waive the copayment for the chest x-ray. You say that you believe that the copayment
for outpatient diagnostics should not apply when you are in the emergency room, and only the emergency room
copayment should apply. The Plan denied your request. The Plan says the emergency room cost sharing only
includes the services of the emergency room. Any additional services will have a copayment.

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 $15
copayment for outpatient x-rays.

You have been asked to pay a $15 copayment for the chest x-ray. The chest x-ray falls within the outpatient x-rays
benefit category. There is nothing in your Evidence of Coverage that states that all services received
during an emergency room visit are encompassed in the emergency room copayment. 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 chest x-ray you had on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 18, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the submitted documentation did not contain a signed physician order.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic services provided on September 29, 2020.
You asked the Plan to waive the copayment for ophthalmic diagnostic services. You say that this was a post-operative follow-up and you feel that the services should be included under a previous surgical procedure. 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 $20 copayment per visit to an ophthalmologist for vision care. You received ophthalmic diagnostic services on September 29, 2020. Post-operative visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for ophthalmic diagnostic services. Ophthalmic diagnostic
services fall within the vision 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 copayment for ophthalmic diagnostic services provided on September 29, 2020.