Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report (CPT code 93312) and doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete (CPT code 93320) provided to the enrollee on March 15, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. CPT code 93312-26-59 (1 unit) remains not supported. This code is included in CPT code 00562; therefore, it cannot be separately reimbursed. The documents received do not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. In addition, the submitted medical records do not indicate that echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report was performed. Therefore, the billed CPT code and modifiers cannot be verified. 

CPT code 93320-26 (i unit) remains not supported. The required primary service code (CPT code 93312) is denied in the claim processing system (Reason Code 193); therefore, this service cannot be reimbursed separately. In addition, the submitted medical records do not indicate that doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete was performed. Therefore, the billed CPT code and modifier cannot be verified. Therefore, we decided that the Plan does not have to pay for echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report (CPT code 93312) and doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete (CPT code 93320) provided to the enrollee on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for inpatient hospital services billed will Diagnosis Related Group (DRG) 377 billed for dates of service July 13, 2020, to July 18, 2020.  You asked the Plan to pay for DRG 377. You say that DRG 377 accurately describes what transpired during this stay. The Plan denied your request. The Plan says that based on the medical records, DRG 377 isn't supported.  The Plan says that DRG 378 should have been billed instead.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 377. 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 DRG 377. Our reviewer says that DRG 377 is supported by the medical records. Our physician reviewer found that the use of secondary diagnosis code N17.0 (acute kidney failure with tubular necrosis (ATN)) was supported by the medical records. Our physician stated that the enrollee had laboratory evidence of acute kidney failure, and the clinical documentation by the nephrologist documents a diagnosis of acute tubular necrosis due to hypotension and GI bleeding causing anemia. The physician also noted that the urinalysis with sediment examination by urine microscopy is normal or near normal in prerenal disease. The classic urinalysis in ATN reveals muddy brown granular, epithelial cell casts, and free renal tubular epithelial cells. The urine-sodium concentration (fractional excretion) tends to be low in prerenal disease in an appropriate attempt to conserve sodium and high in ATN due, in part, to impaired tubular function induced by the tubular injury. The gold standard for the distinction between prerenal disease secondary to volume depletion and postischemic or nephrotoxic ATN is the response to fluid repletion. If sufficient fluid is given to reverse any signs of volume depletion, return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent correction of prerenal disease, whereas persistent acute kidney injury is considered to represent ATN.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services billed will Diagnosis Related Group (DRG) 377 billed for dates of service July 13, 2020, to July 18, 2020.   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the myelography services provided on August 25, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 72270 was billed with code 72132. We find that CPT code 72270 may be eligible for payment when billed with this code pair. The claim does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the myelography services provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) provided July 19, 2021.
You asked the Plan to pay for the emergency treatment of dental pain. You say that you don't feel any treatment was done and you should not be responsible for the cost. The Plan denied your request. The Plan says this service is not covered under your 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, as billed, are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) provided July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from August 10, 2021, through August 13, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that based on the records we have, this might be an observation stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 10, 2021, through August 13, 2021.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 28, 2021.  

You asked the Plan to pay for the dental service. You say that you feel this service should be covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on August 17, 2021.  

You asked the Plan to pay for the therapy services and vitamin injections. The Plan denied your request. The Plan says these are non-covered benefits.    

The Plan must follow Medicare rules. Medicare rules say that Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services and vitamin injections have not been met. Specifically, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy.   

In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the therapy services and vitamin injections provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal x-ray services provided on September 4, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 74018 was billed with code 74420. We looked at the file and the rules. We find that CPT code 74018 may be eligible for payment when billed with this code pair. The claim does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray services provided on September 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from September 1, 2020, through September 10, 2020.

You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says the services are not supported.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria has been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided from September 1, 2020, through September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, 83970, 84100) provided to the enrollee on June 9, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The Centers for Medicare and Medicaid Services (CMS) has an established policy for patients with ESRD indicating that the dialysis center is responsible for laboratory services related to the treatment of ESRD. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, 83970, 84100) provided to the enrollee on June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
June 17, 2021, through June 20, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290
copay per day, for days 1-5 for each stay, for inpatient hospital care rendered by an in-network provider.
You have been asked to pay $870 ($290 copayment x 3 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from June 17, 2021,
through June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or 
injection, major joint or bursa) (CPT code 20610) provided on July 6, 2021, 

You asked the Plan to waive the copayment for the service. You say that you have a $0 copayment for 
diagnostic tests, x-rays, labs service and radiology services. You state you had the same issue in 2016 and 2017 
and the Plan determined you did not have a copayment. You state that for the current claim your 
rheumatologist scheduled an appointment with the provider for you to have a cortisone injection into your hip 
using an x-ray guidance machine. You state you did not have an appointment with a specialist.  The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 

Review of the file shows that you received arthrocentesis, aspiration and/or injection, major joint or bursa) 
(CPT code 20610) on July 6, 2021, by a specialist. The CPT code 20610 is a surgical code, which was rendered 
in a specialist office. This provider is considered a Radiologist which is a specialty and services rendered by 
this provider would be considered specialty services. Therefore, you were asked to pay a $15 copayment for the 
service. 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 arthrocentesis, aspiration and/or injection, 
major joint or bursa) (CPT code 20610) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191, 81309) provided on April 13, 2021.  You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene codes, when either 5-50 or more than 50 gene panels are ordered, is considered incorrect coding. Correct coding requires that when a panel code is ordered, it should be billed, rather than the individual gene codes.   We looked at the file and Medicare rules. The panel at issue was billed with individual gene codes rather than a panel code. Based on this information, we decided that Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus gene panel (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191, 81309) provided on April 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70496) provided to the 
enrollee on August 14, 2021.

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 an appropriate modifier was not used in this case.

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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services (procedure code 70496) provided to the 
enrollee on August 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 12, 2021.
You asked the Plan to pay for procedure code 99053. You say that additional payment is warranted for the level of care the patient received. The Plan denied your request. The Plan says this procedure code is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that procedure codes with a status indicator of 'B' are never separately payable because they are bundled into other codes. In this case, procedure code 99053 has a status indicator of 'B' in the Medicare Physician Fee Schedule Relative Value File. Based on this information, we decided that Medicare rules separate payment of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided to the enrollee on August 5, 2021, by out-of-network providers.

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 drug testing (CPT code G0480) provided to the enrollee on August 5, 2021, by out-of-network providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power scooter.
You asked the Plan to pay for a power scooter. You say that the item should be covered. The Plan denied your request. The Plan says you obtained this item from a provider that is not Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a power scooter