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

 We decided that the Plan does not have to pay for injection services (procedure code 77003) provided to the enrollee on February 23, 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 the Type I add-on code 77003 was billed with an acceptable primary procedure code which is not eligible for payment to the same practitioner for the same patient on the same date of service.  T

he 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 77003 is "Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary 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 per the provider remittance advice, the provider billed CPT coded 99213, 95991, 77003, and 97535. CPT 77003 is an add on code. The code description has instruction to use "Use 77003 in conjunction with 61050; 61055; 62267; 62273; 62280; 62281; 62282; 62284; 64449; 64510; 64517; 64520; 64610;96450:)" As "in conjunction with" codes were not performed and reported during the procedures documented, this add on code would not be billed separately.  

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 injection services (procedure code 77003) provided to the enrollee on February 23, 2021
.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 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 81256 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 81256 is HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D).  We find that CPT code 81256 is not supported in the medical record. Specifically, the records show that the testing was performed via buccal swab, not a whole blood sample.  Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99281) provided on August 14, 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 $65.59 for the emergency care visit provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment.  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 (99281) provided on August 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 44346, 49905) provided to the enrollee on June 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 the denied codes remain not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of the denied codes is:  CPT 44346:  Revision of colostomy; with repair of paracolostomy hernia (separate procedure)  CPT 49905:  Omental flap, intra-abdominal (List separately in addition to code for primary 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 servcies. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found in terms of CPT 44346, the operative report describes a hernia repair and colostomy was performed through the same incision, therefore, these services should not be reported separately. In terms of CPT 49905, the operative report documents "We created an omental flap and placed this around the conduit and secured it with 0-Uicry, to provide a layer between the mess and bowel loops." The operative report does not describe a surgical recipient site of a flap from the transverse colon and ligation of vessels. Therefore, this procedure cannot be confirmed as performed.   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 servcies have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 44346, 49905) provided to the enrollee on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-covered chiropractic service (98943) provided on September 7, 2021.  You asked the Plan to pay for code 98943. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 98943 is not payable when billed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.      The records show that the service at issue, code 98943, is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic service (98943) provided on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to reimburse you for face down recovery equipment (E1399) provided by an out-of-network provider on July 20, 2021.  You asked the Plan to reimburse you for face down recovery equipment. You say that your physician referred you for this service. The Plan denied your request. The Plan says that the provider at issue is out-of-network and not a Medicare certified provider.  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. When a contracted provider furnishes a service or refers an enrollee for a service that an enrollee reasonably believes is a plan-covered service, the enrollee cannot be financially liable for more than the applicable cost-sharing for that service. The Plan follows these rules.  You were referred for face down recovery equipment by a contract provider. The file does not show that the Plan provided notice that face down recovery equipment would not be covered. Under Medicare rules, this means face down recovery equipment is considered approved by the Plan. You cannot be held liable for more than the Plan required cost-sharing, which is 20% coinsurance for DME. Therefore, we decided that the Plan has to reimburse you for face down recovery equipment (E1399) provided by an out-of-network provider on July 20, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on August 16, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.   We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on July 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that these services were emergency care. The Plan denied your request. The Plan says these services were not emergent or authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

The records indicate that this visit was a follow-up and was not emergent. Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on July 13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulatory surgical center services provided September 20, 2021.  You asked the Plan to waive the copayment for the ambulatory surgical center services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment for ambulatory surgical center services.   You have been asked to pay a $250 copayment for ambulatory surgical center services. 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 ambulatory surgical center services provided September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled nursing or skilled therapy needs that can only be provided on an inpatient basis.  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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of 1/26/22, you do not require any skilled nursing or skilled rehabilitation services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time, or require skilled therapy to prevent deterioration with mobility or ADLs. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an inpatient basis, at a skilled nursing facility level of care as of 1/26/22.  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 not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 19, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the care could have been done under an observation stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone replacement graft (D7953) provided on August 16, 2021.  You asked the Plan to pay for dental codes D4266 and D7953. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D4266 and D7953 are not covered under the Plan's supplemental dental benefit.  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, dental codes D4266 and D7953 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone replacement graft (D7953) provided on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for fluoroscopic guidance (77002) provided on August 23, 2021.  You asked the Plan to pay for fluoroscopic guidance. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary 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, we have confirmed that code fluoroscopic guidance is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance (77002) provided on August 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the somatosensory testing (95938) provided on June 17, 2021.  

You asked the Plan to pay for the somatosensory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was not billed with an appropriate diagnosis code.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   

We find that CPT code 95938 is not supported in the record. Specifically, the LCA for the governing Medicare Appeal Contractor states that any codes not listed do not support the medical necessity of the service. Code I71.01 is not listed as a diagnosis code which supports medical necessity. Based on this information, we decided that Medicare rules for coverage of the somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for the somatosensory testing (95938) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services (D6069, D6057, D6242) provided June 11, 2021.  

You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says the pontic is part of an implant bridge and is therefore non-covered. The remaining services are not listed as covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D6069, D6057, D6242) provided June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services rendered on January 23, 2020 to  May 5, 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 was not filed timely.  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. The Plan covers supplemental dental benefits and claims must be received within 12 months of receiving the services.    We looked at the file and Medicare rules. The file shows that the claim for the services received on  January 23, 2020 was not received until May 4, 2021. The claim was not received within 12 months of you receiving these services. The implants received on May 5, 2021 are not covered because these services are not covered by your supplemental dental benefit. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on January 23, 2020 to May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87507, 87493) provided September 16, 2021.  You asked the Plan to pay for laboratory services. You say that the services provided were medically necessary and provided in good faith. The Plan denied your request. The Plan says the services were provided out-of-network 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (87507, 87493) provided September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit services provided on July 6, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit services provided on July 6, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging and laboratory services provided on July 28, 2021 by an out-of-network (OON) provider. 

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 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the imaging and laboratory services provided on July 28, 2021 by an out-of-network (OON) provider.