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

We decided that the Plan does not have to waive the cost sharing amounts for the ambulance services, durable medical equipment and physical therapy services provided on January 28, 2021, through March 8, 2021.

You asked the Plan to waive the cost sharing amounts for the ambulance services, durable medical equipment and physical therapy services. You say that you would like reconsideration for the cost share amounts assessed. The Plan denied your request. The Plan says your cost share has been assessed appropriately.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for ambulance services, 20% coinsurance for durable medical equipment and a $40 copayment for each physical or speech therapy visit.

You have been asked to pay a $350 copayment for ambulance services, 20% coinsurance for durable medical equipment and a $40 copayment for each physical or speech therapy visit. 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 amounts for the ambulance services, durable medical equipment and physical therapy services provided on January 28, 2021, through March 8, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic pathogen/antibiotic resistance testing provided on May 17,
2021.

You asked the Plan to pay for the pathogen/antibiotic resistance testing. You say that these tests should be
reimbursed due to medical necessity. The Plan denied your request. The Plan says that these services are not
authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on
the claim and are done for screening purposes.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.

This testing was ordered by a contract provider. The file does not show that the plan provided notice that the
pathogen/antibiotic resistance testing would not be covered. Although the Plan argues that this is screening
testing that is never covered by Medicare, this is not a valid rationale. This testing was done due to the
enrollee's urinary tract infection. The contract provider ordered this testing to determine the pathogenic cause
of the infection, as well as any antibiotic resistance. While this may or may not be medically necessary, under
Medicare rules, this means the pathogen/antibiotic resistance testing is considered approved by the plan. The
medical necessity of otherwise covered tests cannot be challenged for tests ordered by a network provider.
Therefore, we decided that the Plan has to pay for the genetic pathogen/antibiotic resistance testing provided on
May 17, 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 medical services rendered by the out-of-network (OON)
provider on June 18, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider on
June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (72170) provided March 1, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed on the same service date by the same provider.

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 72170 has a Column One/Column Two relationship with code 73501 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (72170) provided March 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95938, 95861 and 95940) provided on February 16, 2021.

You asked the Plan to pay for the intraoperative neuromonitoring services. You say that you would like reconsideration because you are requested by the hospital and pay the technician. The Plan denied your request. The Plan says this provider is not recognized for payment.

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 95938, 95861 and 95940 is not supported in the medical record. Specifically, only the physician services are separately reportable when the member is in an inpatient setting. Payment for these services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95938, 95861 and 95940) provided on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for LTACH care. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided February 5, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that after having hip surgery your leg is uneven, you have major pain when walking and have had falls. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) treatment.

You asked the Plan to pre-approve the Prolia treatment. You say that this treatment is medically necessary for the enrollee's osteoporosis to prevent fractures. The Plan denied your request. The Plan says this cannot be covered while the enrollee has active hypocalcemia.

The Plan follows Medicare rules. Medicare rules say that Prolia may be covered to treat osteoporosis for enrollees without hypocalcemia.

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 Prolia treatment. Our reviewer says that the criteria for the requested use of Prolia are not met in this case. Our physician reviewer found the records clearly show that the enrollee suffers from osteoporosis but also has hypocalcemia. There is no evidence that there has been treatment to correct this condition. Until the enrollee's low calcium levels are corrected, the use of Prolia is not reasonable and 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 Prolia treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from February 11, 2020, to February 16, 2020, and billed with DRG (diagnosis related group) 871.

You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the diagnosis of sepsis due to Streptococcus pneumoniae is not supported.

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 DRG 871, which is defined as septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complications or comorbidities. 

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 care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the records show that there was no evidence of a dysregulated host response to infection. Platelets, creatinine and total bilirubin were within normal limits. The record did not show significant or persistent hemodynamic instability, cognitive impairment or end-organ dysfunction that would be consistent with multi-system involvement due to sepsis. 

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 care provided from February 11, 2020, to February 16, 2020, and billed with DRG (diagnosis related group) 871.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care (99239) provided January 29, 2021.

You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 99239 is hospital discharge day management of more than 30 minutes. 

We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not show that more than 30 minutes was spent on this service.

Based on this information, we decided that Medicare rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care (99239) provided January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for ostomy supplies provided on March 23, 2020.

You asked the Plan to provide additional reimbursement for the ostomy supplies. You say that you would like reconsideration because the Plan should pay 80% for durable medical equipment. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. 

The Plan paid $11.94 for the durable medical equipment. The Medicare allowed amount for these supplies is $14.92. 80% of $14.92 is $11.94. 

You have been reimbursed 80% of the Medicare allowed amount for these supplies. These supplies fall within the durable medical equipment benefit category. This means that you have been reimbursed 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 provide additional reimbursement for ostomy supplies provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (A4314, & A4357) provided June 1, 2021.

You asked the Plan to pay for the medical supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the claim was submitted with an invalid place of service.

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 A4314, & A4357 is not supported in the medical record. Specifically, Place of Service 31 was billed, however the enrollee was not under a Part A covered stay. Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (A4314, & A4357) provided June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (99072) provided February 17, 2021.

You asked the Plan to pay for the medical supplies. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is 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, 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. 

We find that CPT code 99072 is not supported in the medical record. Specifically, payment for this service is bundled in payment for the primary service billed.

Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (99072) provided February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87481, 87640, 87653) provided November 20, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 find that CPT codes 87481, 87640, & 87653 are not supported in the medical record. Specifically, the place of service listed on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87481, 87640, 87653) provided November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on June 23, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the x-ray. You say that the type of radiology charge that was submitted on the claim does not need a referral. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the x-ray provided on June 23, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a doppler echocardiograph (93320) provided June 3, 2021.

You asked the Plan to pay for the doppler echocardiograph. You say that two echocardiographs were
performed on the same day. The Plan denied your request. The Plan says the claim was submitted without a
required modifier.

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 93320 is not supported in the medical record. Specifically, CPT 93320 shares a bundled
relationship with CPT 93308 which was also billed. The claim was not billed with a modifier required to
denote a separate and distinct service. Based on this information, we decided that Medicare rules for coverage
of the doppler echocardiograph have not been met. Therefore, we decided that the Plan does not have to pay for
a doppler echocardiograph (93320) provided June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82306, 84443, 80053, 83036, 85025) provided March 11, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided for screening reasons and are non-covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (82306, 84443, 80053, 83036, 85025) provided March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care visit (99291) provided on February 23, 2021.

You asked the Plan to pay for the critical care visit. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

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 critical care visit. Our reviewer says that CPT code 99291 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not include time spent performing critical care to confirm 30-74 minutes were performed. Since critical care is a time-based code, the physician's progress note must contain documentation of the total time involved providing critical care services. 

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 critical care visit have not been met. Therefore, we decided that the Plan does not have to pay for the critical care visit (99291) provided on February 23, 2021.