Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have a pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).
You asked the Plan a pre-approve a PET CT scan from the skull base to mid-thigh. 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. Medicare rules say that PET scans are covered only when they are medically necessary. 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 a pre-approve a PET CT scan from the skull base to mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found there are no pathology results in the submitted records and there is no signed order for PET/CT. Absent these items medical necessity has not been established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan from the skull base to mid-thigh have not been met. Therefore, we decided that the Plan does not have a pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee from May 2, 2020, to May 27, 2020.

You asked the Plan to pay for home health services as billed. You say that that this claim was paid by the Plan and then recouped by the Plan. You are appealing for full payment. The Plan denied your request. The Plan says that that the claim is being repriced using the edited "M items answers" and a lower HIPPS code has been generated and validated.

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. Home Health services are paid based on the HIPPS code billed. The Plan states they downgraded the HIPPS code because the occupational therapy evaluation and the 'Start of care Oasis' by Physical therapy contradicted one another. However, the Plan failed to explain what the contradiction was. It is the Plan's obligation to clearly define their denial, which they have failed to in this case. As the Plan has failed to explain what the contradiction was and why that contradiction should result in a different HIPPS code (and therefore lower payment), they have not supported their decision Therefore, we decided that the Plan has to pay for home health services provided to the enrollee from May 2, 2020, to May 27, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (PCD) with full leg appliance rendered on February 10, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that pneumatic compression devices (PCDs) coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

We looked at the file and Medicare rules. The file shows that the enrollee does not have chronic venous insufficiency with venous stasis ulcers. 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 pneumatic compression device (PCD) with full leg appliance rendered on February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (70450) provided to the enrollee on April 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 an appropriate modifier was not billed in this case.

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 70450 is "Computed tomography, head or brain; without contrast material." 

We find that CPT code 70450 is not supported in the medical record. Specifically, this code cannot be billed separately from CPT 70496 without a modifier present. 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 imaging services (70450) provided to the enrollee on April 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin D and magnesium testing provided on March 9, 2021.
You asked the Plan to pay for the vitamin D and magnesium testing. You say that this testing was all necessary prior to prescribing narcotics to ensure what substances the enrollee is taking and to prevent adverse reactions. The Plan denied your request. The Plan says this testing was not provided for a covered indication.
The Plan must follow Medicare rules. Medicare rules say that vitamin D and magnesium testing may be covered when the enrollee's diagnosis is listed as supporting of medical necessity in the applicable LCDs and related Policy Articles. The reported diagnoses on the claim do not include any of the diagnosis codes listed in the two LCDs cited in the Medicare rules section. There is no other information which supports that this testing was provided for a covered indication. Therefore, we decided that the Plan does not have to pay for the vitamin D and magnesium testing provided on March 9, 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 the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on November 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on February 23, 2021, to February 27, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that an executive order was signed, and you should not have to pay a copayment for having Coronavirus. The Plan denied your request. The Plan says the copayment you are being charged is 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 $225 copayment per day, for days 1-7 and a $0 copayment per day, for days 8-90, for inpatient hospital care.

You have been asked to pay a $225 copayment for inpatient hospital care. The records show that you were inpatient for four (4) days for a total cost share of $900 ($225 x 4 days = $900). The EOC confirms that $225 is the required copayment for this service. Please note, per the Plan's Coronavirus declaration, members who were admitted to an in-network hospital and test positive for Coronavirus will have no member cost-share through June 1, 2020. 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 inpatient hospital care provided on February 23, 2021, to February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on the enrollee on June 10, 2021.

You asked the Plan to pay for this service. 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 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 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 out of network physician services provided on the enrollee on June 10, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the CORUS coronary artery disease (CAD) test provided on August 14, 2020.

You asked the Plan to pay for the CORUS CAD testing. You say that this testing was covered by the controlling LCD on the date of service. The Plan denied your request. The Plan says that Medicare has rules which state for CORUS testing, the manufacturer has failed to demonstrate that testing resulted in improved patient outcomes or that testing changed physician management to result in improved patient outcomes.

Please note: The rules cited by the Plan above are not applicable to the billing laboratory's state. In addition, the rules cited in the Medicare rules section were in effect for the State of Texas on the date of service in question. For this reason, these were the rules applied in this case.

The Plan must follow Medicare rules. Medicare rules say that for services provided before September 24, 2020, CORUS CAD testing is covered for the indications listed in the Medicare rules sections for certain diagnoses. 

This claim is for services provided prior to September 24, 2020. The relevant rules indicate that this testing may be covered when provided for diagnoses R12 (Heartburn) and I10 (Hypertension). Therefore, we decided that the Plan has to pay for the CORUS coronary artery disease (CAD) test provided on August 14, 2020.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the low osmolar contrast material used during the computed tomography (CT) scan you had on May 12, 2021.

You asked the Plan to waive the coinsurance for the low osmolar contrast material. You say that you believe this charge is an error and you want the Plan to review it. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for medical supplies, including chemical agents used in diagnostic procedure.

You have been asked to pay 20% coinsurance for the low osmolar contrast material. The low osmolar contrast material falls within the medical 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 the low osmolar contrast material used during the computed tomography (CT) scan you had on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (76380) provided to the enrollee on April 16, 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 a modifier was not billed in this case.

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 find that CPT code 76380 is not supported in the medical record. Specifically, this code cannot be paid separately from CPT 74177 without a modifier present. A modifier was not used in this case. 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 imaging services (76380) provided to the enrollee on April 16, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided from May 15, 2020 to June 13, 2020.

You asked the Plan to pay for home health services billed to the enrollee. You say that this claim was paid by the Plan and then recouped by the Plan. You are appealing for full payment. The Plan denied your request. The Plan says that the claim is being repriced using the edited "M items answers" and a lower HIPPS code has been generated and validated. 

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. Home Health services are paid based on the HIPPS code billed. The Plan states they downgraded the HIPPS code because the occupational therapy evaluation and the 'Start of care Oasis' by Physical therapy contradicted one another. However, the Plan failed to explain what the contradiction was. It is the Plan's obligation to clearly define their denial, which they have failed to in this case. As the Plan has failed to explain what the contradiction was and why that contradiction should result in a different HIPPS code (and therefore lower payment), they have not supported their decision. Therefore, we decided that the Plan has to pay for home health services provided to the enrollee from May 15, 2020, to June 13, 2020.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex is experimental. More research is needed to show it is safe and effective. 

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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy rendered on June 2, 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 97010 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 97010 (hot or cold packs therapy) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy rendered on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit you had with a neurologist on June 17, 2021.
You asked the Plan to reduce the copayment for the neurology visit. You say that you were overcharged for a primary care provider (PCP) visit. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the provider you say is not your PCP nor are they contracted with the Plan as a PCP. This provider is a neurologist.
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 visits with a specialist.
You have been asked to pay a $40 copayment for the neurology visit. The neurology visit falls within the visits with a specialist 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 copayment for the office visit you had with a neurologist on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for dental services (D1999) received on June 21, 2021.
You asked the Plan to pay for the services. You say that you were not aware of the rules. The Plan denied your request. The Plan says that this service is covered once monthly until June 30, 2021.
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 denial has not been substantiated in this case. The plan has stated that this service was covered once monthly until June 30, 2021. However, there is no plan contract that shows this information, and there is no evidence that you were informed of this limitation. Therefore, we decided that the Plan has to pay for dental services (D1999) received on June 21, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast tomosynthesis and screening mammogram rendered on March 31, 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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 breast tomosynthesis and screening mammogram rendered on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided to the enrollee on June 1, 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 an appropriate modifier was not 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 70450 is "Computed tomography, head or brain; without contrast material." 

We find that CPT code 70450 is not supported in the medical record. Specifically, this code cannot be paid separately from CPT 70496 without a modifier. A modifier was not reported in this case. 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 radiology services (70450) provided to the enrollee on June 1, 2021.