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

 We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 14, 2020, through June 16, 2020.  You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says the determination to remove secondary diagnosis code J96.01 (Acute respiratory failure with hypoxia) is upheld.  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 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 inpatient hospital care. Our physician reviewer found documentation submitted was reviewed and does not meet criteria. Secondary diagnosis of J96.01 Acute respiratory failure with hypoxia is not support by the medical record. Documentation throughout this hospital stay is not clear consistent. The enrollee presented to emergency department with complaints of worsening shortness of breath and chest pain. While in the emergency department stay, the enrollee's oxygen saturation dropped to 87% was placed on 2L oxygen and increased to 93%. Throughout hospital stay, the oxygen saturation remained above 90%, no respiratory distress was documented. Acute respiratory failure is documented by the provider in the emergency department note, subsequent hospital note, and the discharge summary, however during the course of this hospital stay clinical manifestations and treatment for acute respiratory failure are not documented.   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 care provided to the enrollee from June 14, 2020, through June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on February 26, 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 the service is not supported by the records.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99100 has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for eye specialist visits provided from September 30, 2021, to October 19, 2021.  You asked the Plan to reduce the copayments for the eye specialist visits. You say that you believe that the provider is in-network based on the Plan's information. 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 $40 copayment for each out-of-network (OON) exam to diagnose and treat diseases and conditions of the eye.   You have been asked to pay a $40 copayment for each out-of-network (OON) eye specialist visit. Please note that the Plan has indicated that the provider services two different facilities. The facility utilized for your services is not contracted with the Plan. The eye specialist visits fall within the Vision 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 reduce the copayments for eye specialist visits provided from September 30, 2021, to October 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on May 3, 2021, through May 15, 2021.  You asked the Plan to waive the copayment for the SNF care. You say that there should not be a cost share. The Plan denied your request. The Plan says the cost share was applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $160 copayment for each day 21 through 100; the first 20 days are fully covered for skilled nursing facility (SNF) care.    The enrollee has been asked to pay a $160 copayment for each day 21 through 100; the first 20 days are fully covered for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. Our records indicate the enrollee received SNF care for 26 days. The First 20 days were covered, and the enrollee is responsible for the remaining 6 days. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on May 3, 2021, through May 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided from February 19, 2021, through April 9, 2021.  You asked the Plan to pay for the additional supplies and materials. You say that CPT code 99072 was established to report additional practice expenses incurred during a public health emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from February 19, 2021, through April 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox 200-unit injection, for the enrollee.  

You asked the Plan to pre-approve the injection. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee's dose exceeds the accepted standard of medical practice and is not supported by a review of the enrollee's medical records.  

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 injection. Our physician reviewer found the record indicates that the enrollee has hemiplegia and hemiparesis with upper extremity spasticity secondary to spinal meningitis. The requested dose is 500 units per three months. The Medicare approved compendia indicate that when treating 1 or more indications in adults, the maximum cumulative dose of onabotulinumtoxin should generally not exceed 400 units in a 3-month interval and be limited to 50 unit per site. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox 200-unit injection, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two crowns (D2750 x2) provided on June 14, 2021.  You asked the Plan to pay for the crowns. You say that this procedure was necessary for health and cosmetic reasons. The Plan denied your request. The Plan says these services are not a covered expense under your dental 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two crowns (D2750 x2) provided on June 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic procedures (97112 and 97110) and manual therapy techniques (97140) provided on June 29, 2021.  You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of units 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.  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 therapy services. Our reviewer says that CPT code 97112 does not meet criteria for billing or reimbursement consideration. The medical records submitted does not include sufficient documentation to support 2 units of  the time-based services billed, therefore these services cannot be verified.  CPT code 97110 does not meet criteria for billing or reimbursement consideration.   The medical records submitted does not include sufficient documentation to support 1 unit of  time-based code 97110 GO, therefore, this service cannot be verified. Our reviewer found CPT code 97140 does not meet criteria for billing or reimbursement consideration. The medical records submitted does not include sufficient documentation to support i unite of time-based code 97140 GO 59, therefore this service cannot be verified.  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 therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures (97112 and 97110) and manual therapy techniques (97140) provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99204) and diagnostic radiology services (73502, 72100) provided on August 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit and diagnostic radiology services. You say that your doctor referred you to a specialist out of your network and he sent all the necessary x-rays and information. You also say that this current provider did her own x-rays and charged you for it. The Plan denied your request. The Plan says this service was done by a non-participating provider , the referral was not authorized by the attending physician, and services were not authorized by network/primary care providers.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99204) and diagnostic radiology services (73502, 72100) provided on August 23, 2021 by an out-of-network (OON) provider.   Your complaint about the doctor potentially taking extra x-rays while nothing was wrong with your arm 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 the anesthesia services coded as 99100 provided on February 27, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this service is 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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  We looked at the file and Medicare rules. In this case, code 99100 has a Status Code of "B" under the Physician Fee Schedule indicating that it is a Bundled Code. This means that payment for this service is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on February 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder Monitor test (CPT code 0013M) provided to the enrollee on June 15, 2021.  You asked the Plan to pay for the service. You say that you believe the enrollee's benefits cover this service. The Plan denied your request. The Plan says the service is not covered.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The rules say non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for the Cxbladder Monitor test (CPT code 0013M) 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 the injection services provided on May 11, 2021.  You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services must be processed by the enrollee's primary insurer.    The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the injection services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the injection services provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on August 3, 2020.  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 the services are not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99100 has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on March 18, 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 the service is 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. CPT code 99100 has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the OON provider on June 10, 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 laboratory service (88305) rendered by the OON provider on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on November 13, 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 procedure code 88364 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 88364 is in situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure).  

We find that CPT code 88364 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 laboratory services rendered on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for comprehensive electrophysiologic evaluation including insertion and repositioning (CPT code 93654) and intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (CPT code 93662-26) provided to the enrollee on August 16, 2021.  

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not 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.  

Review of the records show the provider rendered procedure code 33249 on date of service July 12, 2021. This code has a global day value of 090. This is a major procedure that has a global surgery period of 90 days. Procedure 93654 billed on date of service August 16, 2021, is included within the global surgery package of procedure 33249 billed on date of service July 12, 2021. Additionally, procedure code 93662-26 is an add-on code to procedure code 93654 and is not eligible for payment without a paid primary code. 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 comprehensive electrophysiologic evaluation including insertion and repositioning (CPT code 93654) and intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (CPT code 93662-26) provided to the enrollee on August 16, 2021.