Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unattended electrical stimulation (G0283) and vitamin B injection (J3420) provided during a Sanexas device treatment on June 22, 2021.

You asked the Plan to pay for the services rendered. You say that this should be covered by the Plan. The Plan denied your request. The Plan says this is an experimental treatment and cannot be covered.

The Plan must follow Medicare rules. Medicare rules say that therapy services are only covered when provided by certified therapists. IN addition, compounded drugs must be billed used the NOC code J7999. 

G0283 is a therapy service and was billed by a provider who is not a therapist. In addition, the use of vitamin B was in a prefilled syringe with compounded drugs. This should be billed with one unit of J7999. Therefore, we decided that the Plan does not have to pay for the unattended electrical stimulation (G0283) and vitamin B injection (J3420) provided during a Sanexas device treatment on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lipid panel testing provided on July 2, 2021.
You asked the Plan to pay for the testing services. You say that your doctor wanted you to have blood work done. The Plan denied your request. The Plan says coverage of the service is limited.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). We looked at the file and the rules. The file shows that you last received lipid testing services on April 23, 2020. Your plan only covers this testing once every 5 years. The testing falls within the cardiovascular disease testing benefit category. Therefore, we decided that the Plan does not have to pay for the lipid panel testing provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from June 29, 2021, to July 1, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that these services were billed inaccurately and with wrong dates. The Plan denied your request. The Plan says this claim was processed correctly with supporting documentation, and your copayment was assessed in accordance with your contract.

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 $300 copayment for each time you are admitted to an acute care hospital.

You have been asked to pay a $300 copayment for the inpatient care. Medical records support the inpatient admission on the dates billed. 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 the inpatient hospital services provided from June 29, 2021, to July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the endodontic therapy (D3310) provided on August 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the endodontic therapy. You say that the Plan should have covered 50% of the cost stated in the quick start guide. The Plan denied your request. The Plan says the OON excess amount was applied correctly per your plan benefits.
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, you are responsible for a 50% coinsurance, plus the difference between the billed amount and allowed amount for the endodontic therapy having been received OON. Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D3310) provided on August 9, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genomic sequencing testing provided on April 5, 2021.
You asked the Plan to pay for the testing services. You say that the test results were needed to help determine the course of treatment for this enrollee. The Plan denied your request. The Plan says the testing is unlikely to impact therapeutic decision making.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
The file shows that FoundationOne Heme testing was provided. We find that the testing is not supported in the medical record. In this case, there are insufficient medical records to show that the results of the testing will impact clinical management to improve outcomes for this specific enrollee. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for genomic sequencing testing provided on April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from July 5, 2020, to July 8, 2020, and billed
with DRG (diagnosis related group) 871.
You asked the Plan to pay for inpatient care. You say that this was billed with the correct DRG. The Plan
denied your request. The Plan says that the diagnosis of sepsis is not supported.
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. Although the Plan indicated that medical records were submitted by the provider
and referenced records in the decision rationale, the Plan did not include these medical records in the submitted
case file. Without this information, the denial cannot be verified. Therefore, we decided that the Plan has to pay
for inpatient care provided from July 5, 2020, to July 8, 2020, and billed with DRG (diagnosis related group)
871.
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 pay for the respiratory pathogen panel provided on September 14, 2020.
You asked the Plan to pay for the pathogen panel. You say that this should be covered. The Plan denied your request. The Plan says this is not billed with an appropriate POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network provider.

You asked the Plan to pre-approve podiatry services with an out-of-network provider. You say that you would like a visit with the out-of-network provider. The Plan denied your request. The Plan says there are participating providers that you can see.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from December 9, 2020, to December 14, 2020.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you never spoke to a doctor while there and you had a fall but were never unconscious. You stated that you were not hooked up to IVs or a heart monitor. You were not satisfied with the stay, so you should not have to pay the copayment. 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 $295 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for four days. You were charged a $295 copayment per day, for a total of $1180. This copayment applies regardless of your satisfaction with the services received. 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 the inpatient hospital services you received from December 9, 2020, to December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal duplex scan interpretation provided on July 19, 2021, billed with code 96976.

You asked the Plan to pay for the billed code 93976. You say that the imaging should be covered as multiple exams were done on the same date. The Plan denied your request. The Plan says this was not billed with an NCCI modifier as required.

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 the billed code 93976 is a column II code to column I code 76857. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal duplex scan interpretation provided on July 19, 2021, billed with code 96976.
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 the enrollee is medically ready for discharge
from the hospital but will need intensive rehabilitation at a SNF since she has no help at home. The Plan denied
your request. The Plan says the records do not show the enrollee requires daily skilled services that can only be
provided in a SNF. The Plan says that physical therapy can safely be received at a different setting. The Plan
says that SNF care is not medically necessary.

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 the enrollee received oral medications,
had stable vital signs, and had clear lungs. The enrollee received physical therapy and occupational therapy.
The enrollee was at a standby assist to contact guard assist level for functional mobility, including gait to 50
feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs but they are not required on a daily basis.
The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF
setting.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing (CPT code(s): 87481, 87491, 87529, 87591, 87640, 87651, 87653, 87661, 87798 and 87511) provided to the enrollee on June 16, 2021.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says 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.

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 test at issue in this appeal, the testing, was 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 molecular genetic screening testing (CPT code(s): 87481, 87491, 87529, 87591, 87640, 87651, 87653, 87661, 87798 and 87511) provided to the enrollee on June 16, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve repeat paravertebral facet joint nerve destruction for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical documentation provided reports only one of the two cervical medial branch blocks yielded 80% pain relief.
The Plan must follow Medicare rules. Medicare rules say that repeat radiofrequency ablation is covered if the first procedure had 50% pain improvement over six months. 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the repeat diagnostic blocks were not medically necessary. However, the request is for repeat radiofrequency ablation (RFA). The prior RFA achieved greater than 80% pain relief for more six months, and therefore, this request is medically 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 services have been met. Therefore, we decided that the Plan has to pre-approve repeat paravertebral facet joint nerve destruction for the enrollee.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110-KX (4 units)) provided to the enrollee on June 22, 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 service is not supported by the records and of note there is an appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0151) for the billed 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 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 service. Our reviewer found the review has determined that the service was not supported by the medical record provided. 

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 service have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110-KX (4 units)) provided to the enrollee on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pulmonary provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the services are related to a routine visit for pulmonary nodule evaluation.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network pulmonary provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on August 17, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $90 copayment for each emergency care visit. 

You have been asked to pay a $90 copayment for the emergency room visit provided. 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 the emergency room visit (99284) provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy or excision of lymph node(s); open, superficial
(CPT code 38500) provided to the enrollee on May 4, 2021.

You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied
your request. The Plan says the service is not covered.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code
38500. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure.

This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be
paid. Based upon this information, we find that Medicare coverage criteria for the service have not been met.
Therefore, we decided that the Plan does not have to pay for the biopsy or excision of lymph node(s); open,
superficial (CPT code 38500) provided to the enrollee on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgical services (CPT code(s): 44121, 44120, 44050) provided to the enrollee on March 26, 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 payment is not allowed for these services because the appropriate provider type is not billed on the claim. The Plan states this claim cannot be reprocessed for payment until a corrected claim is received.
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 surgical services (CPT code(s): 44121, 44120, 44050) provided to the enrollee on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had at an orthopedic
surgery office on May 12, 2021.
You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that you made an
appointment to see a doctor, not a physician's assistant. You do not think you should have to pay this
copayment. 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 $50
copayment for physician and practitioner services in a specialist's office.
You have been asked to pay a $50 copayment for the orthopedic surgery visit. This copayment applies to both
physician and practitioner (i.e., non-physician) services you receive in a specialist's office. 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 the office visit you had at an
orthopedic surgery office on May 12, 2021.