Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy and occupational therapy visits provided from August 14, 2019 to September 9, 2019.
You asked the Plan to reduce the copayments for the physical therapy and occupational therapy visits. You say that you should only be charged a $10 copayment because you were receiving therapy on an outpatient basis. The Plan denied your request. The Plan says you have been charged 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 $40 copayment for physical therapy and occupational at an in-network outpatient hospital. You have been asked to pay a $40 copayment for each of the physical therapy and occupational therapy visits. ($40 x 8 visits = $320). The physical therapy and occupational therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows you were billed by the facility.
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 reduce the copayments for the physical therapy and occupational therapy visits provided from August 14, 2019 to September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 23, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
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 a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Home Infusion Therapy (S9328) provided February 27, 2019 to April 22, 2019.You asked the Plan to pay for the infusion. You say that the services were medically necessary and should be covered.The Plan denied your request. The Plan says code S9328 is not valid for Medicare reimbursement.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 S9328 is not supported. Specifically, code S9328 is marked with "I" which means it is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the infusion have not been met.Therefore, we decided that the Plan does not have to pay for Home Infusion Therapy (S9328) provided February 27, 2019 to April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis services provided to the Enrollee on August 26, 2019.
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 Current Procedural Terminology (CPT) code 20611 remains 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 20611 is "Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting." 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 coded correctly. Our physician reviewer found the medical records indicate Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting was performed on both knees. The claim submitted to the health plan included billing of CPT code 20611 50 at 1 unit. This indicates the service was performed bilaterally. This line of service was paid on the claim and included payment inclusive of both knees. It is inappropriate to bill CPT 20611 again on the same claim with a 59 modifier and an RT modifier due to additional aspiration or injection of one or more of the surrounding bursae on the right knee. 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 arthrocentesis services provided to the Enrollee on August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for labs provided on May 2, 2019.
You asked the Plan to waive the copayment for labs. You say that you disagree with the charges because the labs were part of an annual wellness visit. 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 $5 copayment for labs. You received labs on May 2, 2019. Labs are not included in wellness exams and are subject to cost-sharing charges. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for labs. Labs fall within the outpatient diagnostic tests and therapeutic services and supplies 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 labs provided on May 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forEmergency Room Services provided August 21 and 22, 2019 by "the hospital".You asked the Plan to waive the copayment forthe Emergency Room Services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the Emergency Room Services. The Emergency Room Services fall within the Emergency 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 forEmergency Room Services provided August 21 and 22, 2019 by "the hospital".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit (99213) provided on May 20, 2019.You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99213 is included in CPT code 96401 and the documentation submitted does not support a significant, separately identifiable evaluation and management service to support the use of the -25 modifier.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 outpatient visit has a bundled relationship with code 96401 and cannot be paid as billed. This code cannot be paid as a separate line item. Additionally, the record does not support that a separately identifiable evaluation and management service was rendered to support the use of the -25 modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an outpatient visit (99213) provided on May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home infusion injections received from May 24, 2019 to August 11, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you have never had to pay for this. The Plan denied your request. The Plan says the claim was processed appropriately according to your benefits and the services rendered.
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 Medicare Part B covered drugs. You have been asked to pay 20% coinsurance for the injections. The injections falls within the Medicare Part B covered 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 home infusion injections received from May 24, 2019 to August 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasonic guidance (CPT 76942) provided to the enrollee on July 3, 2019.
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 Medicare requires that this procedure has modifier 26.
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 76942 is "Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation." 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 coded correctly. Our coding reviewer found CPT 76942 was performed in an Ambulatory Surgical Center, place of service (POS) 24. CPT 76942 has a PCTC indicator of 1. Because the professional portion of CPT 76942 service was furnished in the same place of service (payment locality) 24, that the Technical portion of CPT 76942 was performed (POS 24) and the Professional portion of CPT 76942 was not submitted with an appended 26 modifier, it is not eligible for reimbursement consideration. 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 ultrasonic guidance (CPT 76942) provided to the enrollee on July 3, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reduce the copayment for the abscess drainage provided on August 24, 2019.
You asked the Plan to reduce the copayment for the abscess drainage. You say that you went to the emergency room. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $90 copayment for each emergency room visit. for The Plan says you must pay $165.52 for an outpatient hospital visit. Based on the Plan contract, however, you cannot be asked to pay more than a $90 copayment for an emergency room visit. The records show that the abscess drainage was billed with an emergency room visit in an emergency room place of service. Therefore, we decided that the Plan has to reduce the copayment for the abscess drainage provided on August 24, 2019.
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 debridement of nail(s) (11720) provided on September 13, 2019 by out of network provider.
You asked the Plan to pay for debridement of nail(s). You say that this member's claim is being denied for unbundling. According to Medicare guidelines, you can bill these two codes together with the correct modifier. You bill visit codes and debridement codes together all the time and only once in a while you get this denial. You have attached a copy of the progress notes for the date of service for your review. You were told you did not need prior authorization for the services billed to this member. The Plan denied your request. The Plan says services are not authorized because the provider is a non-network provider who does not work with the member's health plan, and the member was referred by another provider who also does not work with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 has network providers available who can provide 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 debridement of nail(s) (11720) provided on September 13, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the Enrollee on August 28, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records indicating the billed tests had been performed.
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 a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the Enrollee on August 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the continuation of SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says continued SNF services are not medically necessary. The plan say that the enrollee does not require continued inpatient skilled services on a daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF following hip fracture status-post surgical repair. The enrollee has been refusing therapies since January 3, 2020 and has been ambulating in his room without an assistive device. The enrollee's prior level of function was living in a hotel and being independent with mobility and activities of daily living. The enrollee's current level of function is modified independent with transfers, bed mobility, toileting, upper and lower body bathing and dressing. The records do not support that the enrollee needs or is participating in daily physical and occupational therapy. There are no noted daily skilled complex nursing needs. The enrollee is ambulating household distances and requires little assistance with mobility and transfers. The records do not support the need for daily therapy. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography services provided to the enrollee on July 15, 2019.
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 that Current Procedural Terminology (CPT) code 95870 remains 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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is "Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters." 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 reviewers says that the services at issue in this case were coded correctly. Our coding reviewer found pedicle screws were placed by the surgeon to perform intraoperative neuromonitoring EMGs. The appellant provided the intraoperative monitoring from outside of the OR. Therefore, the appellant has billed for the professional component of the EMG. The surgeon/hospital would bill for the technical component of the EMG. The documentation supports the code as billed. 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 been met. Therefore, we decided that the Plan has to pay for needle electromyography services provided to the enrollee on July 15, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the services provided on September 3, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the billed services were misrepresented.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there may be evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial.Therefore, we decided that the Plan has to pay forthe services provided on September 3, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services (90833, 95812, 99214, 90792) provided from July 3, 2019 to August 14, 2019.
You asked the Plan to waive the copayment for the physician services. You say that the copayment should be waived. The Plan denied your request. The Plan says the proper cost sharing 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 $65.00 copayment for Specialist Visits. You have been asked to pay a $65.00 copayment for the physician services. The physician services at issue fall within the Specialist 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 physician services (90833, 95812, 99214, 90792) provided from July 3, 2019 to August 14, 2019.