Persius/hicric huggingface dataset:
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive the services required in another setting.

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, there is no documentation that the member requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 

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 waive the coinsurance for a Medicare Part B drug provided on October 13, 2020.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not informed of the additional charges and thought that you would only owe a $30 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 20% coinsurance for Part B drugs. 

You received a Medicare Part B drug on October 13, 2020. The allowed amount is $1,115.27 and 20% of that is $223.05. 

You have been asked to pay the total coinsurance amount of $223.05 for a Medicare Part B drug. A Medicare Part B drug falls within the Part B 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 a Medicare Part B drug provided on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 15734) provided to the enrollee on October 3, 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 the records do not support the services 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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk." 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the operative note indicates that the flap was created using the gracilis muscle from the thigh. The elements of the CPT code are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 15734) provided to the enrollee on October 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening laboratory services (80053, 80061, 83880, 84443, 85025, 87077, 87088, 87186, 81003) provided on November 2, 2020.

You asked the Plan to pay for screening laboratory services. You say that these services should be covered. The Plan denied your request. The Plan says these services were performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal, screening laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening laboratory services (80053, 80061, 83880, 84443, 85025, 87077, 87088, 87186, 81003) provided on November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for foot surgery (28208, 28124, 28122) provided on February 5, 2021.

You asked the Plan to pay for foot surgery. You say that these procedures are separately payable. The Plan denied your request. The Plan says these procedures require a modifier for payment.

The Plan must follow Medicare rules. Medicare rules say that two current procedural terminology (CPT) modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure. Modifier "-79" reports an unrelated procedure by the same physician during a postoperative period.

We looked at the file and Medicare rules. The services at issue were performed during the postoperative period of procedure 64782 but were not billed with a modifier to indicate they are unrelated and separately payable. Based on this information, we decided that Medicare rules for coverage of foot surgery have not been met. Therefore, we decided that the Plan does not have to pay for foot surgery (28208, 28124, 28122) provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care services coded 99226, and
the advance care planning services coded 99497 provided on November 16, 2020.

You asked the Plan to pay for the subsequent observation care services and the advance care planning 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 payable.

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 99226 and 99497 are not supported in the medical record. Specifically, this claim was
billed with outpatient place of service, 22. The documentation shows that the enrollee was inpatient during this
date of service. This means that the place of service billed was inappropriate. Based on this information, we
decided that Medicare rules for coverage of the subsequent observation care services and the advance care
planning services have not been met. Therefore, we decided that the Plan does not have to pay for the
subsequent observation care services coded 99226, and the advance care planning services coded 99497
provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided by an out-of-network provider on February 12, 2020.

You asked the Plan to pay for the nursing facility care. You say that the use of telehealth providers prevented transfer to the providers office and the hospital. You say that the charges should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 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 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 nursing facility care provided by an out-of-network provider on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on October 6, 2020.

You asked the Plan to pay for the laboratory test. You say that the definitive testing performed should be considered medically necessary and you are requesting payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 laboratory test provided by an out-of-network provider on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (64999) provided October 22, 2020.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says an appropriate CPT code was not 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. 

We find that CPT code 64999 is not supported in the medical record. Specifically, per National Correct Coding Initiative Policy Manual, Chapter 2 Anesthesia Services, anesthesia services must be reported with CPT codes 00100-01860 followed by a description of a surgical intervention. CPT code 64999 should not be billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (64999) provided October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
January 30, 2021, and February 2, 2021.

You asked the Plan to pay for the office visits. You say that you were unaware this specific doctor was nonparticipating
and that specific services weren't covered. The Plan denied your request. The Plan says services
by non-participating providers are not covered and the only covered chiropractic service is manual
manipulation.

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 by an out-of-network
provider on January 30, 2021, and February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for skin substitute graft (CPT 15271) services provided to the enrollee on October 28, 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 the records do not support the service 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 15271 is "application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100sq cm; for the first 25sq cm or less wound surface area." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided did not include sufficient documentation to validate that an application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100sq cm; for the first 25sq cm or less wound surface area was performed on October 28, 2020, therefore this service cannot be verified. 

We looked at this coder's review, the file, and Medicare rules. 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 skin substitute graft (CPT 15271) services provided to the enrollee on October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 4, 2020, to August 7, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you thought that inpatient hospital care was included in the COVID-19 waiver. 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 $290 copayment for days 1-5 for inpatient hospital care. 

You received an inpatient hospital stay from August 4, 2020, to August 7, 2020. Inpatient hospital stays are not included in the COVID-19 waiver. Therefore, you are responsible to pay a $290 copayment for days 1-3 (August 4, 2020, to August 6, 2020). $290 (copayment) x 3 (inpatient days) = $870. 

You have been asked to pay the total copayment amount of $870 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from August 4, 2020, to August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the preventive medicine counseling and/or risk factor reduction intervention (99403) provided on December 8, 2020.

You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that numerous unsuccessful attempts were made to obtain medical records from the provider.

The Plan must follow Medicare rules. Medicare rules say that Plans must have processes in place for making timely coverage decisions (initial requests and appeals), which includes soliciting clinical documentation, such as medical records, when necessary. Additionally, Medicare does not pay for the services of a Naturopath. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the Plan requested medical records unsuccessfully for clarification on the services provided. According to the information provided in case file, the services are considered as naturopathic services which are not covered under the Plan contract or by Medicare for any condition. Therefore, we decided that the Plan does not have to issue reimbursement for the preventive medicine counseling and/or risk factor reduction intervention (99403) provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on December
21, 2020.

You asked the Plan to pay for the dental service. You say that this was for an oral surgeon and not a regular
checkup. You say this was for a consultation for your embedded wisdom teeth. The Plan denied your request.
The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years. The Plan also says that the
frequency limit has been exceeded.

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 and comprehensive oral evaluation is
listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for this
service that you received on July 22, 2020. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation provided on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 2, 2020.

You asked the Plan to pay for the comprehensive evaluation. You say that your last dentist tried to charge you more money than you knew your copay should be, so you felt you had to find a new dental provider. The new dentist required another comprehensive evaluation, and you feel an exception for coverage should be made in your case. The Plan denied your request. The Plan says only one comprehensive oral evaluation will be covered every three plan years. You previously had a comprehensive evaluation in June 2020 which was already paid for.

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 items or services are requested in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and the comprehensive oral evaluation (D0150) received August 13, 2020.

You asked the Plan to pay for the dental services (D0210, D0150). You say that you are a network provider with the Plan. The Plan denied your request. The Plan says you were not a network provider with the Plan on this date of service.

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. The Plan records indicate that the provider did not show participating status effective until September 25, 2020. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and the comprehensive oral evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intubation services coded 31500 provided on April 25, 2020.
You asked the Plan to pay for the intubation 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 31500 is intubation, endotracheal, emergency procedure. We find that CPT code 31500 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of intubation, endotracheal, emergency procedure; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the intubation services have not been met. Therefore, we decided that the Plan does not have to pay for the intubation services coded 31500 provided on April 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade 100mg solution (J1745).
You asked the Plan to pre-approve the Remicade. You say that Remicade is medically necessary. The Plan denied your request. The Plan says rules for coverage under Medicare Part B are not met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Remicade 100mg solution (J1745).
Benefits for the Remicade may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.