Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 602 provided from November 16, 2020 to November 23, 2020.  You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the billing of the principal diagnosis code A41.9: Sepsis, unspecified organism with DRG 602. The Plan denied your request. The Plan says the medical records do not support the billing of the principal diagnosis code A41.9: Sepsis, unspecified organism with DRG 602.  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 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 the inpatient hospital services. Our reviewer says that the medical records do not support the billing of the principal diagnosis code A41.9: Sepsis, unspecified organism with DRG 602. Our physician reviewer found the enrollee presented with left leg pain, swelling, and erythema and was found to have cellulitis. The respiratory exam included "No respiratory distress." Vital signs relayed oxygen saturations per pulse oximetry were 93-98% on room air. The emergency department (ED) nursing assessment indicated no new or unexplained change in mental status, noting the enrollee was oriented to person, place, and time. The history and physical also described the enrollee as alert and oriented x3. Blood pressure monitoring indicated noninvasive mean arterial pressures greater than 70. Laboratory findings included platelets greater than 150,000 per microliter and total bilirubin less than 1.2 mg/dl. While the serum creatinine level was elevated, the record indicates the enrollee has end-stage renal disease (ESRD) on dialysis at baseline. The Lactic acid was within reference range at 1.5 mmol/L. It is acknowledged the enrollee presented with temperature 100.1?F, pulse 117, respiratory rate 20, white blood count (WBC) 13.6, and infection source, cellulitis, which was treated with IV antibiotics. However, a dysregulated host response to infection is not evident in the documentation received. The review indicates that the medical records did not support the billing of principal diagnosis code A41.9: Sepsis, unspecified organism with DRG 602.   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 with diagnosis related group (DRG) 602 provided from November 16, 2020 to November 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on January 4, 2021.    You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted 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 code billed.  The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable control system and power seat elevation system.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee's upper limb strength is adequate for the enrollee to control the power options using their own switches.  The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.  The file shows that an expandable control system was requested. 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 there is documentation the enrollee has adequate upper limb function and strength to control the approved power options with their own switches. Provided records document that the enrollee has 4/5 to 5/5 bilateral upper extremity strength and is independent with feeding, grooming, dressing, and bathing. These assessments indicate she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.  The file also shows that a power seat elevation system was requested. This item is non-covered because it is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable control system and power seat elevation system.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pay for the anesthesia services (01402). We decided that the Plan does not have to pay for code 64447.   You asked the Plan to pay for the anesthesia services (01402) and anesthetic agent (64447). You say that you would like the Plan to reconsider their denial of payment. The Plan says that the services are not supported.  We decided that the Plan has to pay for the anesthesia services (01402).   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 01402 is Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty.  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 anesthesia services (01402). Our reviewer says that the medical records support the billing of code 01402. Our physician reviewer found that the documentation submitted includes an anesthesia report documenting a total knew arthroscopy, and therefore would be covered.  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 anesthesia services (01402) have been met. Therefore, we decided that the Plan has to pay for the anesthesia services (01402).   We also decided that the Plan does not have to pay for code 64447.  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 64447 is a column II code to column I code 01402. 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 code 64447.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received on July 29, 2021.  You asked the Plan to waive the copayment for the lab services. You say that you were told there was no copayment for an annual wellness visit. The Plan denied your request. The Plan says you were charged this copayment correctly.  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 $5 copayment for diagnostic lab services.   You have been asked to pay a $5 copayment for the lab services. Your contract explicitly states that diagnostic tests rendered as part of an annual wellness visit are subject to separate cost sharing. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services you received on July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.  You asked the Plan to pre-approve the procedure. You say that  The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 you are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.  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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided to the enrollee on June 15, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 medical services provided to the enrollee on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213-25) provided on June 2, 2021.  You asked the Plan to pay for an office visit. You say that this was a significant exam and was separate from the procedures performed. The Plan denied your request. The Plan says the records do not support modifier -25.  The Plan must follow Medicare rules. Medicare rules say that modifier "-25" is used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure.  The physician may need to indicate that on the day a procedure or service that is identified with a code was performed, the patient's condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.  We looked at the file and Medicare rules. The records indicate that the office visit that took place was not separate and distinct for the procedure performed on this date of service. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213-25) provided on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for microsurgery (procedure code 69990) provided to the enrollee on May 11, 2020.  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 there are no modifiers that are allowed with this code pair.  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 69990 is a column II code to column I code 63042. This claim has not been billed with an appropriate modifier to bypass the edit, as there is no appropriate modifier to use in this case. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for microsurgery (procedure code 69990) provided to the enrollee on May 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a joint injection provided on April 16, 2021.  You asked the Plan to waive the copayment for the injection. You say that your copayment was only $35, which you paid. You also say that you received the injection in your doctor's office, but it is being processed as a surgical procedure in an operating room. 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 $285 copayment for surgical services received in an outpatient hospital.   You have been asked to pay $242.94, which is less than the $285 copayment for the injection. The joint injection you received is considered a surgical procedure. The record shows that the injection was received at an outpatient hospital. The injection falls 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 copayment for a joint injection provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services, first 30-74 minutes (99291) and electroencephalogram (EEG) (95816) for dates of services 4/23/2021 to 04/25/2021  You asked the Plan to pay for the hospital services. You say that you will find a copy of the medical records for the date in question. After review of the attached documentation, prompt processing of this claim is kindly appreciated. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.  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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and code 95816 is electroencephalogram (EEG); including recording awake and drowsy.  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 hospital services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer found the provider billed for CPT 99291 and CPT 95816 for date of service April 23, 2021 and CPT 99291 for date of service April 24, 2021 and CPT 99291 and CPT 95816 for date of service April 25, 2021, however no documentation was submitted by this provider for these services, and therefore would not be covered.  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 hospital services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services, first 30-74 minutes (99291) and electroencephalogram (EEG) (95816) for dates of services 4/23/2021 to 04/25/2021
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for home health services you received from April 7, 2021, to May 7, 2021.  You asked the Plan to waive the cost sharing for the home health services. You say that you believe you should not be responsible for the cost sharing for these dates because you had met your out-of-pocket maximum for the year. The Plan denied your request. The Plan says you had not met your annual out-of-pocket maximum until after the claim for the May 7, 2021, date of service had processed.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for home health services.   You have been asked to pay 20% coinsurance for the home health services. The Plan provided a breakdown of all of your claims for 2021.  This breakdown shows that you had not yet met your out-of-pocket maximum until after the claims for the dates of service in question processed.  As a result, the coinsurance for these services applies. 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 home health services you received from April 7, 2021, to May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assistant surgery services provided on February 23, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for these services.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assistant surgeon services rendered on March 19, 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 provider type is not covered.  The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on March 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.