Persius/hicric huggingface dataset:
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 enrollee has extreme lower back pains and issues walking. You say that the enrollee is a fall risk and has had several falls recently. You say that the enrollee has received physical therapy in her home and needs more intensive care to regain maximum functioning ability.
You say that the enrollee has had a number of procedures for dead nerves in her back, which were not helpful. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and was at a modified independent level with transfers, as well as a supervision/stand by assist level with gait to 120 feet with a rolling walker. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 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: Unfavorable

We decided that the Plan does not have to adjust the cost share for the arthrocentesis and injections provided on January 14, 2021, January 21, 2021 and January 28, 2021.
You asked the Plan to adjust the cost share for arthrocentesis (20610), Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325) and Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose (J7324). You say that the Plan should adjust the bills to one copayment. The Plan denied your request. The Plan says you were charged the cost share 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 $40 copayment for services obtained from a physician specialist and 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $40 copayment for the arthrocentesis obtained from a specialist and 20% coinsurance for the Medicare Part B prescription drugs. 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 adjust the cost share for the arthrocentesis and injections provided on January 14, 2021, January 21, 2021 and January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on February 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and paid due to medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for wound care provided on February 19, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, & 87798) provided August 4, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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. We find that CPT code 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, & 87798 is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service described in the medical records (11, office setting). 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 lab services (87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641,
& 87798) provided August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiology services (73220, 71552)
provided January 27, 2021, to January 29, 2021.
You asked the Plan to waive the coinsurance for the radiology services. You say that you would like this cost
share waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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%
coinsurance for Medicare-covered diagnostic radiology services.
You have been asked to pay a total cost share of $303.33 for the radiology services (1516.69 Medicare-allowed
amount x 20% coinsurance). These services fall within the Medicare-covered diagnostic radiology services
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the radiology services (73220,
71552) provided January 27, 2021, to January 29, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided October 31, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you do not feel you should be responsible for $120 for the emergency room. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage
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 $120 emergency room copayment. You have been asked to pay $120 for the emergency visit. The emergency visit falls 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 for the emergency room visit provided October 31, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of wound services (12031) and emergency department visit (99284) provided December 12, 2020.
You asked the Plan to pay for the repair of wound services and emergency department visit. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does not support these services 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 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. The CPT Code Manual definition of code 12031 is repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less. We asked our coder 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 repair of wound services and emergency department visit. Our reviewer says that the medical documentation does not support the codes as billed. Our reviewer found in this case, the documentation does not support level 99284, history supports an expanded problem focused history. Therefore, a more appropriate level is 99283. In addition, the documentation does not support an intermediate level of closure. Intermediate includes the repair of that, in addition to the simple layered, require layered closure of one or more of the deeper layers of subcutaneous tissue, or documentation of extensive cleaning or removal of particulate matter also constitutes intermediate repair. This was not documented in the records submitted. 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 repair of wound services and emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the repair of wound services (12031) and emergency department visit (99284) provided December 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits and injections (99213, 96372, 36415) provided on March 22, 2021, to March 29, 2021, by an out of network (OON) provider.
You asked the Plan to pay for office visits and injections. You say that you requested to change your primary care provider with the Plan and thought no further action had to be taken. The Plan denied your request. The Plan says services were provided 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 office visits and injections (99213, 96372, 36415) provided on March 22, 2021, to March 29, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and lab work and coinsurance
for an x-ray provided by a participating provider on February 8, 2021.

You asked the Plan to waive the deductible for an office visit and lab work and coinsurance for an x-ray. You
say that you disagree with these charges. The Plan denied your request. The Plan says the correct charges have
been applied.

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 there is a $198 deductible and a 20% coinsurance for physician/practitioner
services/in-network and outpatient diagnostic tests/in-network.

The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit
category physician/practitioner services/in-network and outpatient diagnostic tests/in-network. The Plan has
followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for
physician/practitioner services/in-network and outpatient diagnostic tests/in-network and a 20% coinsurance of
the allowed amount for outpatient diagnostic tests/in-network. This cost sharing is a contractual obligation that had not been met at the time an office visit, lab work, and an x-ray was received on February 8, 2021.

CPT Code
Allowed Amount
Deductible
Amount Being Asked to Pay

99214
---
$109.57
$109.57

85025
---
$2.60
$2.60

71046
$27.68
---
$5.54($27.68 x 20% = $5.54)

Total Amount Being Asked to Pay: $109.57 + $2.60 + $5.54 = $117.71

Therefore, we decided that the Plan does not have to waive the deductible for an office visit and lab work and coinsurance for an x-ray provided by a participating provider on February 8, 2021.
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 you will have heavier onset without therapy. You say that you would have no medical assistance if discharged and that the inpatient rehabilitation facility recommended more rehab through a SNF. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee no longer requires daily skilled services and a continuation of SNF care is not medically necessary.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question, the enrollee was at an MI/stand by assist to contact guard assist level with functional mobility, including gait to 10 feet in the parallel bars. The enrollee required varying assist with activities of daily living. The enrollee tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81293, 81310, 81311, 81314, 81321, 81404, 81405, and 81406) provided March 7, 2021

You asked the Plan to pay for the lab services. You say that the services are medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 

We find that CPT code 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81293, 81310, 81311, 81314, 81321, 81404, 81405, and 81406 is not supported in the medical record. Specifically, the testing panel was billed with multiple unbundled codes. 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 lab services (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81293, 81310, 81311, 81314, 81321, 81404, 81405, and 81406) provided March 7, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planning (D4321 x2) provided on February 24, 2021.
You asked the Plan to pay for periodontal scaling and root planning. You say that the services should be covered, and you want the Plan to pay. The Plan denied your request. The Plan says the services at issue are not covered 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 periodontal scaling and root planning (D4321 x2) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded with 01210 provided July 9, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the records submitted 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 01210 is anesthesia for open procedures involving hip joint. We asked our coder 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 anesthesia services. Our reviewer says that the documentation does not support the criteria for the billed code was met. Our reviewer found the documentation includes evidence that anesthesia services were provided; however, no detailed report of the anesthesia was provided. Therefore, services cannot be confirmed as performed. 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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded with 01210 provided July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 19, 2021.
You asked the Plan to pay for periodontal maintenance. You say that it is a necessary service and you want the Plan to pay. The Plan denied your request. The Plan says the service at issue 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 pay for periodontal maintenance (D4910) provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (20553, 64491, 64492) provided November 23, 2020.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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. We find that CPT codes 20553, 64491, 64492 are not supported in the medical record. Specifically, insufficient evidence was provided to support CPT code 20553. Since this code is not supported, the add-on codes are not supported. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (20553, 64491, 64492) provided November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the labor, plumbing, and installation of a whirlpool bathtub provided July 30, 2020.
You asked the Plan to pay for the labor, plumbing, and installation. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these are not covered items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the labor, plumbing, and installation of a whirlpool bathtub provided July 30, 2020.