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

 We decided that the Plan does not have to pay for the inpatient hospital visits (99232 and 99239) provided on June 25, 2021 and June 26, 2021.  You asked the Plan to pay for codes 99232 and 99239. 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. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99232 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused 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 is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. The definition of code 99239 is Hospital discharge day management; more than 30 minutes.  We find that CPT codes 99232 and 99239 are not supported in the medical record. Specifically, the file shows that the enrollee was admitted as an outpatient on the dates of service at issue in this appeal. Codes 99232 and 99239 are inpatient codes. Based on this information, we decided that Medicare rules for coverage of codes 99232 and 99239 have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital visits (99232 and 99239) provided on June 25, 2021 and June 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110), bitewing x-rays (D0274), periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on September 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the prophylaxis, bitewing x-rays, periodic oral evaluation, and intraoral periapical x-rays. You say that you contacted the Plan around August 30, 2021 inquiring about in-network providers and were told that you would be able to visit this treating provider for a cleaning and x-ray. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider and cannot be covered. The Plan also says that you were given the name of a contracted network provider, who is in the same building as this treating provider but in a different suite, when you contacted the Plan.  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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), bitewing x-rays (D0274), periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), and two additional intraoral periapical x-rays (D0230 x2) provided on September 13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 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 the documentation shows test results for only 20 drug classes.  

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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."  

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 there is insufficient support for medical necessity to test 22 or more drug classes in this case as there was no abnormal urine drug screening results which needed clarification for 22 different drugs or drug classes. Additionally, the records do not support that 22 or more drug classes were actually tested in this case. A count of the drug classes tested comes to 20 and not 22.  

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 drug testing services provided to the enrollee on April 14, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency room services provided to the enrollee on March 5, 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 the claim was billed without the G0 condition code which caused CPT 99282 and 99283 to deny.  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 the denied codes is:  CPT 99282:  Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low 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 low to moderate severity  CPT 99283:  Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused 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 moderate severity  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 Medicare coding guidelines for this claim were not met. This claim was submitted to the payer without a Condition Code of G0 (Multiple Medical Visit Same Day), therefore, 99282 and 99283 are not eligible for reimbursement consideration.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare-covered Part B drugs provided on March 10, 2021.  

You asked the Plan to waive the coinsurance for the services. You say that you are appealing your cost-share responsibility for the services you received. 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 Medicare-covered Part B drugs provided on March 10, 2021. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $1,466.81. The total you owe is $293.36 ($1,466.81 x 20% = $293.36). 

The health plan contract says that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug. 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 Medicare-covered Part B drugs provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infectious agent detection testing provided on January 28, 2021.  You asked the Plan to pay for the infectious agent detection. You say that this was medically necessary. The Plan denied your request. The Plan says this was reported with the incorrect POS code.    The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.  We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection testing provided on January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 12011) provided to the enrollee on June 4, 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 the denied code remains not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 12011 is "Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less."  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 enrollee received emergency department services on June 4, 2021 for a fall.  The documentation supports radiology services and care for a nose fracture. The report does not include documentation of superficial wounds, and therefore cannot be confirmed.  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 surgical services (procedure code 12011) provided to the enrollee on June 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to provide additional reimbursement for the acupuncture visits provided from April 15, 2021, through June 2, 2021.  

You asked the Plan to provide additional reimbursement for the acupuncture services. You say that you have been asked for different information many times during the process of trying to get your reimbursement. You state that you are frustrated by the lack of consistency in how these claims are handled and was is requested/required. The Plan denied your request. The Plan says that a decision could not been made within the allowed timeframe. As such, the case was forwarded to the Qualified Independent Contractor.  

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has indicated that the claims were not reprocessed and that you have not received reimbursement for these services. The Plan has offered no argument to justify why reimbursement has not been made. In some of these cases, reimbursement was made for the subsequent 15 minutes of acupuncture treatment but not for the first 15 minutes. Since no valid reason was given for denial of reimbursement for these services, we find the Plan must reimburse you for these payments, less any applicable cost sharing. Therefore, we decided that the Plan has to provide additional reimbursement for the acupuncture visits provided from April 15, 2021, through June 2, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the services. You say that  The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device.        We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for cataract surgeries (66984) provided on July 15 and July 22, 2021.  You asked the Plan to waive the copayments for cataract surgeries. You say that you cannot afford this bill. The Plan denied your request. The Plan says the correct copayments were 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 $350 copayment for outpatient surgery at a freestanding ambulatory surgical center.   You have been asked to pay a $350 copayment for each instance of two cataract surgeries for a total of $700. Cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayments for cataract surgeries (66984) provided on July 15 and July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 28, 2021 to January 30, 2020.  

You asked the Plan to pay for the services. You say that you disagree with the partial DRG adjustment and recoupment. The Plan denied your request. The Plan says the DRG was updated.  

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.    

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that during the audit of this claim, medical records were requested and not provided and therefore, the claim was partially denied, downgrading from DRG 267 to DRG 307. Upon appeal, medical records were not provided after multiple attempts to obtain. The review has determined that there is no documentation provided to determine support for the DRG and diagnosis codes in this case.   

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 inpatient hospital services provided to the enrollee from January 28, 2021 to January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for knee braces (L1833), suspension sleeves (L2397), and compression stockings (A6531) provided on July 10, 2021.  You asked the Plan to waive the coinsurance for knee braces, suspension sleeves, and compression stockings. You say that the provider specifically told you that everything was free and you would not be responsible for anything. 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 30% coinsurance for Medicare-covered durable medical equipment when obtained from an out-of-network provider.   You have been asked to pay $455.26, or 30% of the Medicare-allowed total charge of $1,517.52, for knee braces, suspension sleeves, and compression stockings. Knee braces, suspension sleeves, and compression stockings fall within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for knee braces (L1833), suspension sleeves (L2397), and compression stockings (A6531) provided on July 10, 2021.   Your complaint about receiving erroneous or incomplete information from the provider 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional unit of initial hospital care (procedure code 99223) provided to the enrollee on November 17, 2020.  

You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your request. The Plan says the submitted documentation supports 1 (one) unit of 99223, which was previously approved/paid.  

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 99223 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital 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 additional unit. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the enrollee was admitted and treated in the hospital for CPT code, 99223 (initial hospital care services) was approved for one unit for 11/17/2020. A second 99223 unit was requested for the same date. This appears to be redundant and by mistake to request for a second repeated code for the same date of service which was already approved. The provided documentation does not clearly explain this request or justify it.  

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 additional unit have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of initial hospital care (procedure code 99223) provided to the enrollee on November 17, 2020.