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

 We decided that the Plan does not have to pay for hospital outpatient clinic visit for specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), or COVID-19 (C9803) infectious agent antigen detection by immunoassay technique (C9803) provided August 7, 2020.  You asked the Plan to pay for the outpatient services. You say that please review the claims as the claims were denied for provider CMS certification letter. The Plan denied your request. The Plan says missing certification.  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. The written confirmation letter granting temporary Medicare billing privileges specifically indicates that an effective date of October 2, 2020. This date of service is prior to the effective date. Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic visit for specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), or COVID-19 (C9803) infectious agent antigen detection by immunoassay technique (C9803) provided August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and complete series x-ray (D0210) provided on June 14, 2021.  You asked the Plan to pay for the dental services. You say that you were advised you could use this provider when you signed up for the plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered.  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, dental services received out of network are not among those covered under this benefit. The record shows that the Dental Plan confirmed that this provider is out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and complete series x-ray (D0210) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an annual wellness exam, immunizations, and a primary care provider visit provided on October 6, 2021.  You asked the Plan to waive the coinsurance for an annual wellness exam, immunizations, and a primary care provider visit. You say that you had a problem scheduling a visit with your regular primary care physician so made an appointment with a new doctor. You state that you were told that the services would be covered. 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 50% coinsurance for out-of-network annual wellness visits, immunizations and physician/practitioner services, including doctor's office visits.   The record shows that you received an annual wellness exam, immunizations, and a primary care provider visit with an out-of-network provider on October 6, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $67.86 and 50% of that is $33.93.   You have been asked to pay the total coinsurance amount of $33.93 for an annual wellness exam, immunizations, and a primary care provider visit. An annual wellness exam falls within the annual wellness visits benefit category. Immunizations fall within the immunizations benefit category. A primary care provider visit falls within the physician/practitioner services, including doctor's office 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 coinsurance for an annual wellness exam, immunizations, and a primary care provider visit provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for nursing facility services (procedure code 99309) provided to the enrollee on April 22, 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 payment is not allowed for this service because it was billed with a modifier that is inappropriate for this procedure code.  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 99309 is "Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; 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 patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit."  We asked our coder 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 supported by the medical records. Our reviewer found the documentation does not support the level of service billed.  There is a more appropriate code to report that is supported by services provided - CPT 99308 as Expanded Problem Focused History, Expanded Problem Focused Exam; and Straightforward Medical Decision making.   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 nursing facility services (procedure code 99309) provided to the enrollee on April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the enrollee on February 24, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered by Medicare or the health plan.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. CPT code 99601 is assigned a status code I = Not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the enrollee on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ostomy pouch (A5073, A4373) and an ostomy deodorant (A4394) rendered from October 24, 2019, to May 25, 2021.  You asked the Plan to waive the coinsurance for an ostomy pouch and an ostomy deodorant. You say that you have been unsuccessful in resolving this matter on your own with both the provider and the Plan. You also say that you have a statement indicating a balance due for two dates of service and are asking for the checking of the billing and the accuracy. The Plan denied your request. The Plan says you were 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 15% coinsurance of the cost for Medicare-covered durable medical equipment (DME).   You have been asked to pay $97.92 in coinsurance, which is 15% of the allowed amount for an ostomy pouch provided on October 24, 2019 ($652.80 allowed amount x 15% coinsurance = $97.92). You have also been asked to pay $53.08 in coinsurance, which is 15% of the allowed amount for an ostomy pouch and an ostomy deodorant provided on May 25, 2021 ($353.86 allowed amount x 15% coinsurance = $53.08). An ostomy pouch and an ostomy deodorant fall within the Durable Medical Equipment 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 an ostomy pouch (A5073, A4373) and an ostomy deodorant (A4394) rendered from October 24, 2019, to May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee orthoses and lumbar sacral orthosis provided to the enrollee on July 21, 2021.  You asked the Plan to pay for the orthoses. You say that that you provided services based on the prescription and the notes they received from the doctor. The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item; or, the supplier has furnished a covered item to the individual and the supplier is contacting the individual only regarding the furnishing of such covered item, or another covered item to this same individual within 15 months. If a supplier knowingly contacts an individual in violation of this prohibition, no payment may be made for any item subsequently furnished to the individual by the supplier.   A review of the file indicates that the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no payment may be made for these items. Therefore, we decided that the Plan does not have to pay for the knee orthoses and lumbar sacral orthosis provided to the enrollee on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 10, 2021 to January 14, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of secondary diagnosis J96.01.  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 secondary diagnosis J96.01 (acute respiratory failure with hypoxia). 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 these services. Our reviewer says that the submitted records do not support the billing of secondary diagnosis J96.01. Our physician reviewer found the records document acute hypoxic respiratory failure on admission, in the progress notes, and in the discharge summary, but supporting medical documentation was incomplete regarding the condition. The physical exam documentation noted no cyanosis, alert, and oriented times three with moderative distress and mild basilar crackles with diminished long sounds on left upper and lower lobes. The documentation is incomplete to reflect a paO2 baseline in a patient with known chronic pulmonary disease requiring home oxygen to determine any acute changes from baseline consistent with acute respiratory failure. The records do not support the billing of secondary diagnosis J96.01.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from January 10, 2021 to January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot insert (CPT code L3020).  You asked the Plan to pre-approve the foot insert. You say that your foot is in so much pain that you can barely walk, and you walk with a limp. You state the doctor believes the orthotics will alleviate the pain. The Plan denied your request. The Plan says orthopedic shoes are only covered if the shoes are part of a leg brace or for a person with a diabetic foot disease. The Plan states there is no indication that the requested shoe inserts are being used in a shoe that is part of a covered brace.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot insert (CPT code L3020).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87481, 87491, 87500, 87556, 87591, 87631, 87640, 87641, 87651, 87653, 87798) provided on June 15, 2021.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87491, 87500, 87556, 87591, 87631, 87640, 87641, 87651, 87653, 87798) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2) and two surgical accesses to an implant body (D6011 x2).  You asked the Plan to pre-approve the endosteal implants and surgical accesses to an implant body. You say that the right side of your mouth does not have a tooth and needs the implant to make the bridge so you can eat. You also say that you cannot eat on one side and the gum on the right side is injured. The Plan denied your request. The Plan says these services are not covered for the purpose of individual implants for prosthetic services of crowns and/or fixed bridges on implants.  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 implant benefit covers only the dental implant to hold a complete denture. The provided documentation shows that you are requesting these implant services in order to make a bridge, which is not covered under your benefit plan. Therefore, we decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2) and two surgical accesses to an implant body (D6011 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services rendered from October 18, 2020 to October 27, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of DRG 871 and diagnosis A41.9.  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 871 and principal diagnosis A41.9 (sepsis, unspecified organism). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 871 and diagnosis A41.9. Our physician reviewer found the documentation supports an admission for pneumonia but is inconsistent regarding a diagnosis of sepsis. Although sepsis was documented, supporting record documentation was not found. The enrollee presented with shortness of breath and bilateral lower extremity edema. There was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. The records did not support the billing of DRG 871 and diagnosis A41.9.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services rendered from October 18, 2020 to October 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the enrollee might be able to get the care they need a home or a long-term care facility.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. There is no documentation that this enrollee requires skilled therapy services. There is no documentation that daily skilled services are required. There is no documentation the enrollee requires the services on an inpatient basis, only in a SNF setting. Records are inadequate to certify a need for skilled nursing or therapy care on a daily basis in a SNF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array (CPT code 63650), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee has completed the required six (6) weeks of physical therapy and has been in so much pain they needed the emergency room. The Plan denied your request. The Plan says that the request is not medically necessary because the enrollee's records show they do not have a condition for which this treatment is medically necessary. The Plan states the enrollee has not had aggressive pharmacological treatment.  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 service. Our physician reviewer found the enrollee meets the NCD criteria for a trial of a SCS. The procedure is medically reasonable and necessary.  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 service have been met. Therefore, we decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array (CPT code 63650), for the enrollee.     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 pre-approve excision of torus mandibularis (21031) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) beyond the Plan's dental allowance.  You asked the Plan to pre-approve removal of bony growth of jawbone inside mouth and intravenous moderate sedation. You say that you need these services in order to be able to eat properly. The Plan denied your request. The Plan says costs beyond your dental allowance are denied. Additionally, the excision of torus mandibularis is not covered under your medical benefits.  Medicare generally does not cover dental services. When an excision of torus mandibularis is performed in connection with an excluded service such as preparation of the mouth for dentures, reimbursement is not made by Medicare. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers supplemental preventative and comprehensive dental services up to a $2,000 dental allowance.  We looked at the file and Medicare rules. In this case the excision of torus mandiubularis is being requested to prepare the mouth for dentures. Therefore, this service is excluded under Medicare coverage. The Plan has pre-approved coverage for services up to your $2,000 dental allowance. Costs above the $2,000 dental allowance are not covered.  Therefore, we decided that the Plan does not have to pre-approve excision of torus mandibularis (21031) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) beyond the Plan's dental allowance.