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

We decided that the Plan does not have to pay for surgical services (44005) provided to the enrollee on
February 9, 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 enterolysis is never separately reportable with an intra-abdominal or pelvic procedure.

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 44005 is "Enterolysis (freeing of intestinal adhesion)
(separate procedure)."

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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found the operative report clearly documents
extensive enterolysis. However, the provider must append an appropriate modifier, as CPT 44005 is inclusive
to another service provided on the same day by the same provider.

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 services have not been met. Therefore, we decided that the Plan does not
have to pay for surgical services (44005) provided to the enrollee on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided from September 22, 2020 to November 3, 2020.

You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received chemotherapy services on the dates of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 Medicare Part B prescription drugs. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received chemotherapy services on September 22, 2020, October 6, 2020, and November 3, 2020. You have been asked to pay a 20% coinsurance for each of the chemotherapy services, totaling $3337.00. The chemotherapy services fall within the Medicare Part B prescription drugs 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 chemotherapy services provided from September 22, 2020 to November 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 2, 2021.

You asked the Plan to pay for physical therapy services. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on March 17, 2021.

You asked the Plan to pay for the hearing aids. You say that that he wouldn't have known the difference between the medical component and hearing network. You say that they should have explained the difference in insurance coverage, and he should be reimbursed $2,900. The Plan denied your request. The Plan says the enrollee utilized a provider that is not in-network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a network provider.

We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; with meniscectomy (29881) and arthroscopy, knee, surgical, abrasion arthroplasty (29879).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the provider did not indicate how long you had conservative care.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Detailed Documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. In addition, there is a noted significant osteoarthritic process in the knee. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. Our physician reviewer found that your condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; with meniscectomy (29881) and arthroscopy, knee, surgical, abrasion arthroplasty (29879).
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room services provided on April 2, 2021.

You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical attention would result in serious jeopardy to their health.

We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with
an average knowledge of medicine would reasonably expect the absence of immediate medical care to
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the emergency
room services provided on April 2, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 9, 2021.

You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.

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 find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for March 9, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amlodipine.

You asked the Plan to pre-approve Amlodipine. You say that the enrollee has been stable on this medication for years. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amlodipine.

Benefits for Amlodipine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on March 1, 2021, to April 3, 2021.

You asked the Plan to waive the copayment for a skilled nursing stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment 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 $0 copayment per day for days 1-20. There is a $184 copayment per day for days 21-100 for skilled nursing facility (SNF) care.

You have been asked to pay a $0 copayment per day for days 1-20 (February 25, 2021 to March 16, 2021). There is a $184 copayment per day for days 21-39 (March 17, 2021 to April 3, 2021) for a skilled nursing stay. The total amount you are being asked to pay is $3,128 ($184 x 17 days = $3,128). A skilled nursing stay falls within the skilled nursing facility (SNF) 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 waive the copayment for a skilled nursing stay provided by a participating provider on March 1, 2021, to April 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of amniotic fluid (fluid flow).

You asked the Plan to pre-approve injection of amniotic fluid (fluid flow). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 injection of amniotic fluid (fluid flow). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has shoulder pain. Fluid Flow solution is injected into the affected ligaments or tendons, which leads to local inflammation. The localized inflammation triggers a wound-healing cascade, resulting in the deposition of new collagen, the material those ligaments and tendons are made of. New collagen shrinks as it matures. The shrinking collagen tightens the ligament and makes it stronger. The use of Amniotic fluid for osteoarthritis and tendonitis is not approved by Food and Drug Administration (FDA).

In addition, FDA has a warning about unapproved stem cell therapies "When stem cell products are used in unapproved ways--or when they are processed in ways that are more than minimally manipulated, which relates to the nature and degree of processing--the FDA may take (and has already taken) a variety of administrative and judicial actions, including criminal enforcement, depending on the violations involved." Therefore, the enrollee does not have a diagnosis/condition that meets criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection of amniotic fluid (fluid flow) have not been met. Therefore, we decided that the Plan does not have to pre-approve injection of amniotic fluid (fluid flow).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided

You asked the Plan to waive the copayment for the medical eye exam and diagnostic imaging of retina. You say that you don't agree with the cost sharing. The Plan denied your request. The Plan says the copayments were 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).

Your contract with the Plan clearly says that you must pay a $45 copayment for Medicare-covered outpatient physician services for the diagnosis and treatment of diseases and conditions of the eye. It also says that there is a $50 copayment for all other Medicare-covered outpatient diagnostic tests 

You have been asked to pay a $45 copayment for the medical eye exam. This exam falls within the Vision services benefit category. You have been asked to pay a $45.84 copayment for the diagnostic retina imaging. This service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The total cost for the diagnostic retina imaging was less than the required copayment for the service. 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 ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87500, 87801, 87798, 87481, 87653, 87491 and 87591 provided on January 25, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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.
We find that CPT codes 87500 and 87801 are not supported in the medical record. Specifically, these codes were already paid on the original claim. This means these codes are duplicates and are not separately payable.
In addition, we have confirmed that codes 87500, 87801, 87798, 87481, 87653, 87491 and 87591 for the laboratory services have a bundled relationship with code 87801 and cannot be paid as billed. These codes cannot be paid as separate line items. 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 laboratory services coded 87500, 87801, 87798, 87481, 87653, 87491 and 87591 provided on January 25, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies
provided on January 22, 2021.

You asked the Plan to pay for therapeutic CGM supplies. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, because the documentation submitted does not support the necessity of the billed code.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for insertion of biomechanical devices (codes 22853 and 22854) provided on January 25, 2021.

You asked the Plan to pay for surgical assistant services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation does not support the codes billed.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage or payment for a service, the information submitted by the provider must corroborate the medical records and confirm that coverage criteria have been met.

We looked at the file and Medicare rules. The documentation submitted does not support the billing of codes 22853 and 22853 for a surgical assistant. Specifically, the operative report submitted does not show that the billing provider performed surgical assistant services for the codes billed on this date of service. Based on this information, we decided that Medicare rules for coverage of surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services for insertion of biomechanical devices (codes 22853 and 22854) provided on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detoxification treatment from October 5, 2021, forward.

You asked the Plan to pre-approve inpatient detoxification treatment from October 5, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient detoxification treatment from October 5, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 5, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond October 5, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient detoxification treatment from October 5, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient detoxification treatment from October 5, 2021, forward.