Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the inpatient hospital services provided on June 5, 2020, through June 9, 2020 and billed with Diagnosis Related Group code 191.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the documentation supports the billed DRG code. The Plan denied your request. The Plan says that the documentation does not support the secondary diagnosis codes which were billed on the claim.  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 diagnosis codes E66.9 and Z68.41. 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 inpatient hospital services. Our reviewer says that the reported Body Mass Index (BMI) supports the billing of the secondary diagnoses E66.9 and Z68.41. Our physician reviewer found the height and weight quoted by the health plan are the height and weight reported by the enrollee when she arrived at the emergency department.  Once the enrollee was actually weighed, she was found to weigh more and, consequently, to have a higher BMI.  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 the inpatient hospital services provided on June 5, 2020, through June 9, 2020 and billed with Diagnosis Related Group code 191.   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography rendered on June 21, 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 procedure code 95870 is 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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters.  We find that CPT code 95870 is not supported in the medical record. Specifically, there is no documentation that multiple extremities were monitored. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography rendered on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a refill kit for an implantable pump (A4220) provided May 5, 2021.  You asked the Plan to pay for a refill kit for an implantable pump. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is bundled into payment for other services not specified and no separate payment can be made.  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 A4220 is a column II code to column I code 62370. 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 a refill kit for an implantable pump (A4220) provided May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 2, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you had to leave before the appointment was completed, and you feel that you should not have to pay for services not received. The Plan denied your request. The Plan says you have been 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 $30 copayment for each specialist visit.   The record shows that the appointment process was started and vitals were taken. Therefore, you have been asked to pay $29.77, which is less than the $30 copayment for the specialist office visit. Specialist office visits fall 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 copayment for a specialist office visit provided on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on September 1, 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 procedure code G0480 is not covered.  The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used.  We looked at the file and Medicare rules. The provider submitted a claim for procedure codes G0480 (definitive drug testing, 1-7 drug classes) and G0482 (definitive drug testing, 15-21 drug classes). Code G0480 is a column II code with a modifier indicator of 0 when billed with column I code G0482. No separate payment is made for code G0480. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation services.  You asked the Plan to pre-approve the requested services. You say that you cannot sleep due to chronic pain. The Plan denied your request. The Plan says the procedure is considered investigational.  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 requested services. Our physician reviewer found that you have a history of cervical spondylosis without myelopathy, low back pain with radiculopathy, and right hip pain due to osteoarthritis. You have been treated with medications, including opiates, and trigger point injections. Your provider has recommended radiofrequency ablation (RFA) of a peripheral nerve. RFA used for the treatment of peripheral nerve pain is experimental/investigational. Therefore, the requested service at issue in this case are not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the small intestinal endoscopy (44361) provided on September 8, 2021.
You asked the Plan to pay for the small intestinal endoscopy (44361). You say that the procedure report shows two techniques used at two different locations. You say that two separate and distinct procedures were performed, and CPT code 44361 should be reprocessed to pay. The Plan denied your request. The Plan says the benefit for this service is included in the allowance for another service that has already been 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 44361 is small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple. We find that CPT code 44361 is not supported in the medical record. Specifically, the services at issue have an indicator of 3. The record indicates that the Plan has paid for the full value of the highest valued endoscopy plus the difference between the next highest and base endoscopy. Based on this information, we decided that Medicare rules for coverage of the small intestinal endoscopy (44361) have not been met. Therefore, we decided that the Plan does not have to pay for the small intestinal endoscopy (44361) provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on August 18, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions outside of the annual supplemental routine eye exam are not covered.  Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.   We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an Airvo portable oxygen device provided on February 17, 2021.  You asked the Plan to pay for an Airvo device. You say that you need the machine at issue to be able to breathe and that the cost is hard for you to pay as you are on a limited income. The Plan denied your request. The Plan says rules for payment have not been met because purchased oxygen equipment is statutorily non-covered.  The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Airvo device have not been met. Specifically, the record shows that you have purchased the oxygen equipment at issue. Therefore, we decided that the Plan does not have to pay for an Airvo portable oxygen device provided on February 17, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for eyeglasses provided on August 2, 2021.  You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says a corrected claim needs to be submitted to the claims address on the back of the member's I.D. card with a valid service code for claim reconsideration. This claim cannot be reprocessed for payment until a corrected claim is received.  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 the Plan's rules. The file shows that you did not submit sufficient information to justify payment of the claim. The file shows that a corrected claim must be submitted in order to reprocess the claim for payment. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 2, 2021.  You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you were advised that the Plan would cover the first visit with the periodontist. The Plan denied your request. The Plan says this service is not covered. The Plan also says that during your call with the Plan on August 26, 2021 you were not advised that this service would be 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 2, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency room visits provided on October 8, 2021, and October 10, 2021.  You asked the Plan to waive the copayment for emergency room visit.. You say that you went to the emergency room, but there were no beds available, so you returned home. The Plan denied your request. The Plan says the copayment amount was correct.  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 $120 copayment for each Emergency care visit. The total of 2 separate visits to the emergency room totals $240.  You have been asked to pay a $120 copayment for each emergency room visit. Emergency room visits fall within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room visits provided on October 8, 2021, and October 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on June 17, 2021.  You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not considered medically necessary.  Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the excision (11443) and complex repair (13151) provided on March 12, 2021.  You asked the Plan to pay for the excision (11443) and complex repair (13151). You say that the corrected claim was denied as not separately payable then denied again as a duplicate. You say that you have not received any payment on the claim, but the claim should be processed and paid. The Plan denied your request. The Plan says these services are not separately payable.  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 11443 and 13151 are column II codes to column I code 14060. 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 the excision (11443) and complex repair (13151) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 8, 2020.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aids must be ordered through an in-network provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan's hearing vendor.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on  July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on May 27, 2021.  You asked the Plan to waive the copayment for the specialist telehealth visit. You say that the provider should be considered in-network. The Plan denied your request. The Plan says you have been 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 $45 copayment for specialist telehealth services.   You have been asked to pay a $45 copayment for the specialist telehealth visit. Specialist telehealth visits fall 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 copayment for a specialist telehealth visit provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing service (G0483) rendered by the out-of-network (OON) provider on June 7, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing service (G0483) rendered by the out-of-network (OON) provider on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the arthrocentesis and the Part B drugs provided on March 1, 2021.   You asked the Plan to waive the cost sharing for the arthrocentesis and the Part B drugs. You say that you are appealing this claim. The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment for each in-network Medicare-covered specialist visit and 20% coinsurance for in-network Medicare-covered Part B chemotherapy drugs and other Part B drugs.   You have been asked to pay a $35 copayment for the arthrocentesis and $1.39 which is 20% coinsurance for the Part B drugs. The allowed amount is $6.93. ($6.93 x 20% = $1.39). The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drugs 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 cost sharing for the arthrocentesis and Part B drugs provided on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on January 22, 2021.   You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on January 22, 2021.