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

We decided that the Plan does not have to pay for the medical eye exam (92014) and retina photograph (922250) provided on November 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that you would like reconsideration because you were referred to this provider. The Plan denied your request. The Plan says you were not referred to this provider by a network provider and these services were not urgent, emergent or approved in advance.
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 the medical eye exam (92014) and retina photograph (922250) provided on November 12, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the selective catheter placement represented by code 36215 and the angiography represented by code 75710 provided on January 19, 2021.
You asked the Plan to pay for codes 36215 and 75710. You say that the medical records support the billing of CPT codes 36215 and 75710 provided on January 19, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 36215 and 75710 provided on January 19, 2021.
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 36215 is Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. The definition of code 75710 is Angiography, extremity, unilateral, radiological supervision and interpretation.
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 codes 36215 and 75710. Our reviewer says that the medical records do not support the billing of CPT codes 36215 and 75710 provided on January 19, 2021. Our physician reviewer found code 36901 (was covered) is a bundled code that includes the entire fistulogram including any access required to achieve this. Imaging the arterial inflow at the anastomosis is a routine part of a complete fistulogram. Code 36215 codes for selective access of a brachiocephalic vessel from the aorta and this was not documented. Code 75710 codes for an upper extremity arteriogram and this was not documented. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 36215 and 75710 have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement represented by code 36215 and the angiography represented by code 75710 provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy (45380) provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the colonoscopy. You say that you would like reconsideration because the services were rendered in good faith and medically necessary. The Plan denied your request. The Plan says the out-of-network services were rendered without obtaining 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. 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 colonoscopy (45380) provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the flap creation reported for a procedure provided on August 18, 2020 billed with codes 15734-52 and 15734-59.
You asked the Plan to pay for the services as billed. You say that this service was correctly reported. The Plan denied your request. The Plan says the use of these codes with the modifiers is not support by the operative report.
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 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 as billed. Our reviewer says that these services are not supported. Our coding reviewer found the medical records provided do not include sufficient documentation to validate that this service was performed. Per the Nation Correct Coding Initiative Policy Manual regarding 15743 52 and 15734 59, the physician repairs a defect area using a muscle, muscle and skin, or a fasciocutaneous flap. The physician rotates the prepared flap from the donor area to the site needing repair, suturing the flap in place. The donor area is closed primarily with sutures. This description was not included in the operative note. 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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the flap creation reported for a procedure provided on August 18, 2020 billed with codes 15734-52 and 15734-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the need for LTACH care. The Plan denied your request. The Plan says LTACH services are not medically necessary.
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. Our physician reviewer found the enrollee appears to have improved somewhat but requires short-term additional acute care services until more stable that can be safely received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when the enrollee is more stable and/or when treatment has completed.
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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring services coded as G0453, 95938, 95955, 95861, 95868, 95999 provided April 16, 2019.
You asked the Plan to pay for the neurophysiology monitoring. You say that you are not a contracted provider with the Plan and have not agreed to any timely filing guidelines or a reimbursement rate set by the Plan or any other third party. The Plan denied your request. The Plan says the claim was submitted past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the neurophysiology monitoring was not filed until January 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for intraoperative neurophysiology monitoring services coded as G0453, 95938, 95955, 95861, 95868, 95999 provided April 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 22, 2020 to December 29, 2020.
You asked the Plan to pay for the SNF care. You say that the SNF care provided from December 22, 2020 to December 29, 2020 was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the SNF care provided from December 22, 2020 to December 29, 2020.
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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with advanced dementia, Benign Prostatic Hyperplasia (BPH), chronic kidney disease, hypothyroidism and a urinary tract infection. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had routine foley catheter care. He was treated with a comfort care approach. He was treated for a skin tear. Regarding rehabilitation services, the enrollee did not receive nor require skilled care for the dates in question. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on the dates in question. This enrollee did not meet severity of illness or intensity of service criteria for the SNF care provided on the dates in question. 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 care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 22, 2020 to December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of LTACH services.
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. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating provider on February 26, 2021.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you should only owe 20%. 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 $200 copayment for outpatient surgery/other services. You have been asked to pay $198.54 which is less than your copayment amount of $200 for outpatient hospital services. The correct copayment has been applied to the facility charges that occurred. Outpatient hospital services falls within the outpatient surgery/other 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 copayment for outpatient hospital services provided by a participating provider on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received from September 2, 2020, to November 30, 2020.
You asked the Plan to waive the coinsurance for the dialysis services. You say that you believe you had met your out-of-pocket maximum, so you shouldn't have to pay these bills. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You had not yet met your annual out-of-pocket maximum until November 24, 2020. At that time, coinsurance was no longer assessed.
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-covered dialysis treatments. You have been asked to pay 20% coinsurance for the dialysis services. The Plan has confirmed that you had not met your out-of-pocket maximum until November 24, 2020 (at which point they stopped assessing cost sharing.) 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 dialysis services you received from September 2, 2020, to November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (84999) provided on July 7, 2020.
You asked the Plan to pay for laboratory services. You say that this was billed correctly. The Plan denied your request. The Plan says a description of the test performed was not included on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. When billing for unlisted laboratory tests using a Not Otherwise Classified (NOC) code, field 19 of the claim form MUST include the specific name of the laboratory test(s) and/or a short descriptor of the test(s).
In this case, the CPT Code Manual definition of code 84999 is unlisted chemistry procedure. We find that CPT code 84999 is not supported in the medical record. Specifically, a description of what this code is being used to report was not included on the claim form. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (84999) provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on February 3, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says that the Plan only covers eyeglasses when received from a Plan vision network provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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 the Plan's vision network provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's vision network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87798, 87486, and 87581) provided on June 2, 2020.
You asked the Plan to pay for the laboratory services. 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. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87798, 87486, and 87581) provided on June 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Xiaflex (J0775) received on November 17, 2020.
You asked the Plan to waive the coinsurance for Xiaflex. You say that you hold the Plan responsible for misinforming you about the level of coverage to be provided and the Plan should therefore cover the entire cost of the drug. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $961.84, or 20% of the Medicare-allowed charge of $4,809.21, for Xiaflex. Xiaflex falls within the "Medicare Part B prescription 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 treatment with Xiaflex (J0775) received on November 17, 2020.
Your complaint about receiving erroneous or incomplete information from the Plan about your cost-sharing responsibilities is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 29, 2021, to January 31, 2021.
You asked the Plan to pay for the SNF care. You say that the SNF care provided from January 29, 2021, to January 31, 2021 was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the SNF care provided from January 29, 2021, to January 31, 2021.
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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF after a hospitalization for respiratory failure and COVID-19 infection. From a nursing perspective, the enrollee received oral and topical medications. The enrollee had stable vital signs. She tolerated a regular diet. Her lungs were clear. Her skin was intact. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a modified independent level with bed mobility and supervision to contact guard assist level with transfers and gait to 60 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. This enrollee did not meet severity of illness or intensity of service criteria for the SNF care provided from January 29, 2021, to January 31, 2021. 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 care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 29, 2021, to January 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 01810 provided on January 20, 2021.
You asked the Plan to pay for code 01810. 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.
CPT code 01810 has a status code of "J" under the MPFSDB and has no RVUs and no payment amounts. The intent of this value is to identify the anesthesia services. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 01810 provided on January 20, 2021.