Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services described by current procedural terminology (CPT) code 99358 provided on December 9, 2020 to December 14, 2020.
You asked the Plan to pay for CPT code 99358. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99358 is Prolonged evaluation and management service before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the medical record. Specifically, CPT code 99358 is used when a prolonged service is provided that is neither face-to face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of evaluation and management and is beyond the usual physician or other qualified health care professional service time. This code may be reported on a different date than the primary service to which it is related. The provider's documentation in the medical record indicates that the time was spent coordinating care with other providers after face to face time with the patient. Based on this information, we decided that Medicare rules for coverage of CPT code 99358 have not been met. Therefore, we decided that the Plan does not have to pay for the physician services described by current procedural terminology (CPT) code 99358 provided on December 9, 2020 to December 14, 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 July 29, 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. 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 July 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 9, 2020.
You asked the Plan to pay for the ambulance services. 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 September 9, 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 September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided December 23, 2020.

You asked the Plan to pay for the endodontic therapy. You say that your 2021 Evidence of Coverage lists this service as a covered benefit, and you believe the Plan should cover 50% of the cost. The Plan denied your request. The Plan says this service was not covered under your 2020 dental 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 endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided December 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for evaluations on implanted devices (93296, 93282) provided July 20, 2020 to November 16, 2020.
You asked the Plan to waive the copayments for the device evaluations. You say that the copayments were never applied in the past and should be waived. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $65 copayment per test for Diagnostic Tests. You have been asked to pay the Medicare allowable amount of $32.74 per test (for two tests, for a total of $65.48) for the device evaluations. The device evaluations fall within the Diagnostic Tests benefit category.
The allowable amount of $32.74 per test is less than the listed copayment of $65 per test. 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 copayments for evaluations on implanted devices (93296, 93282) provided July 20, 2020 to November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service described by current procedural
terminology (CPT) code 80320 provided on October 13, 2020.

You asked the Plan to pay for CPT code 80320. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, CPT code 80320 has a status code of "I" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have
to pay for the laboratory service described by current procedural terminology (CPT) code 80320 provided on
October 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on November 4, 2020.

You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee's diagnosis is not related to hospice, and the trip is not related to hospice care. 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 ambulance service and ground mileage provided on November 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair van provided on January 20, 2021.

You asked the Plan to pay for a wheelchair van. You say that the hospital called for you to be moved and you did not make the call. The Plan denied your request. The Plan says wheelchair vans are a contract exclusion.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.

You were transported from the hospital to the nursing home via a wheelchair van. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for a wheelchair van provided on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service described by current procedural terminology (CPT) code 86077 provided on December 31, 2020.

You asked the Plan to pay for CPT code 86077. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of CPT code 86077 have not been met.

Therefore, we decided that the Plan does not have to pay for the laboratory service described by current procedural terminology (CPT) code 86077 provided on December 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 17, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not enrolled in hospice on this date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on September 10, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on December 19, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you cannot afford this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $120 copayment for emergency care/in-network.

You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls within the emergency care/in-network 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 emergency room visit provided by a participating provider on December 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on
October 5, 2020.

You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that this service should be
reconsidered for coverage. 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 provided on
October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on July 15, 2020.

You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2025), progressive lenses (V2781), and tinting (V2745) purchased on October 26, 2020.

You asked the Plan to pay for frames, progressive lenses, and tinting. You say that you were told that the eyewear would be covered at the OON provider. The Plan denied your request. The Plan says coverage for routine vision benefits is not available at OON providers and they did not find evidence that misinformation was provided.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames, progressive lenses, and tinting have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. 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 frames (V2025), progressive lenses (V2781), and tinting (V2745) purchased on October 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 74 year old male with lumbar laminectomy and fusion. In this case, while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D5821, D7140, D0120, D1110, D0274, D6740 (x3), D6245 (x2)) received October 28, 2020 through December 10, 2020.
You asked the Plan to pay an additional amount for the dental services. You say that you have a dental benefit that should cover out of pocket expenses. The Plan denied your request. The Plan says coverage rules for the requested services have not been met.
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. For the interim partial denture (D5821) and the extraction, erupted tooth or exposed root (D7140) received October 28, 2020, you were not enrolled in the supplemental dental benefit on this date of service, therefore the Plan cannot provide payment for these procedures. For the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewings x-rays (D0274) received December 3, 2020, these services were performed by an out-of-network provider. The Plan contract states that if you use an out-of-network dentist, your share of the cost may be higher. You are responsible for the difference between the Plan's maximum allowable fee and the amount charged by the out-of-network provider. For the retainer crown (D6740 x3) and the pontic (D6245 x2) received December 10, 2020, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D5821, D7140, D0120, D1110, D0274, D6740 (x3), D6245 (x2)) received October 28, 2020 through December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that had spinal surgery/fusion and were discharged to home. You say that you were able-bodied prior to the spinal surgery, but post-surgery you have lost the use of your right arm and you have lost a lot of strength in your right leg, which caused you not to be able to use your walker, which subsequently resulted in a fall. You say that you still need assistance with getting up and down from bed or a chair and you need help getting to and from the bathroom, needs assistance performing basic functions around the house. You say that you need to get some kind of rehabilitation and treatment as part of your recovery. The Plan denied your request. The Plan says the Medicare criteria for an IRF has 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 that the documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You would be expected to benefit from physical therapy and occupational therapy. However, the documentation does not support that you require at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days of therapy services. It has not been clearly established that in your current condition you 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 IRF admission and services.