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

We decided that the Plan does not have to pay for selective catheter placement services (procedure code 36224) provided to the enrollee on May 17, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a corrected claim has not been received.

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 36224 is "Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed." 

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 code's description of "unilateral" a modifier should be appended to identify laterality.

Per Medicare - "In order to facilitate claims processing and avoid denials for duplicate claims which contain CPT/HCPCS codes describing services performed on anatomic structures that can be distinguished as left or right require laterality modifiers." 

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 selective catheter placement services (procedure code 36224) provided to the enrollee on May 17, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a physician office visit (99213) for removal of an actinic keratosis provided on June 10, 2021.

You asked the Plan to pay for an office visit. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that the services at issue are cosmetic and not a covered benefit.

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. Specifically, the Plan has failed to address the service at issue. The Plan's denial is based on cosmetic surgery, but the code at issue is an office visit. Of note, the record shows that the surgical service has been paid by the Plan. There is no information provided to indicate why procedure code 99213 does not meet criteria for billing or reimbursement consideration. It is the burden of the Health Plan to substantiate the denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for a physician office visit (99213) for removal of an actinic keratosis provided on June 10, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient lift hydraulic chair (E0630) and sales tax (S9999), purchased on July 15, 2021.

You asked the Plan to pay for the patient lift hydraulic chair and sales tax. You say that the item was medically necessary. The Plan denied your request. The Plan says you obtained the item through a provider that does not participate with Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the patient lift hydraulic chair (E0630) and sales tax (S9999), purchased on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received on April 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that this is the second invoice that you received from this provider and feel you should not be responsible for this claim. The Plan denied your request. The Plan says the services received are not a covered benefit.

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. In addition, a review of the file shows that the provider name does not match the National Provider Identifier (NPI) and/or tax ID submitted on the claim. Therefore, we decided that the Plan does not have to pay for the office visit received on April 21, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient psychiatric services provided at an outpatient hospital on December 1, 2020, to May 13, 2021.

You asked the Plan to waive the copayments for outpatient psychiatric services. You say that the services at issue were provided in telehealth visits. The Plan denied your request. The Plan says the correct copayments were 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 $120 copayment in 2020 and a $100 copayment in 2021 for outpatient mental health care when provided at an outpatient hospital.

You have been asked to pay $360, or a $120 copayment for each of 3 outpatient mental health visits in 2020. You have also been asked to pay $700, or a $100 copayment for each of 7 outpatient mental health visits in 2021. The bill submitted by the hospital to the Plan does not support that the services at issue were rendered via telehealth. Outpatient psychiatric services fall within the "Outpatient mental health 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 copayments for outpatient psychiatric services provided at an outpatient hospital on December 1, 2020, to May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wound care treatment with a tertiary level of care pyoderma specialist.  You asked the Plan to pre-approve specialist service. You say that you have seen numerous specialists with no results and your wound is getting worse. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not need to be treated at the tertiary level of care and can be treated by a non-tertiary wound care specialist.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 specialist service. Our reviewer says that you do not meet the Medicare criteria for treatment at the tertiary level of care Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet your needs through referral to a non-tertiary level provider. The documentation does not reveal extenuating factors with your condition that would make it medically necessary for you to see the requested tertiary level provider. The Plan has non-tertiary (community-level) providers who meet the standards of care for treatment of your condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of specialist service have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care treatment with a tertiary level of care pyoderma specialist.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the oral surgery provided on August 19, 2021.
You asked the Plan to pay for the oral surgery. You say that the oral surgery provided on August 19, 2021 was medically necessary to treat a medical condition. The Plan denied your request. The Plan says that the oral surgery provided on August 19, 2021 for the enrollee's diagnosis is not included in Medicare's covered dental services.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the oral surgery. Our reviewer says that the oral surgery provided on August 19, 2021 was medically necessary to treat a medical condition. Our physician reviewer found a review of the enrollee's medical record indicates that due to the dental condition and prior to radiation and chemotherapy dental extractions were recommended. According to the rules of coverage extractions, prior to radiation for cancer treatment are a covered expense. The documentation provided meets the criteria for coverage for the extractions prior to chemo-radiation treatment for nasopharyngeal cancer in this enrollee. 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 oral surgery have been met. Therefore, we decided that the Plan has to pay for the oral surgery provided on August 19, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lightweight wheelchair (CPT code K0003) and general use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware (CPT code E2611), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not approved; however, a standard wheelchair code K0001 and cushion code E2611 are supported for the enrollee based on their records. The Plan states these can be approved for the enrollee instead of the items requested and their provider can call to have these codes approved.  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 DME. Our physician reviewer found the documentation does not reveal that the criteria per Medicare's LCD: Manual Wheelchair Bases (L33788) have been met for a lightweight wheelchair (K0003). The documentation does not indicate that the enrollee is unable to self-propel in a standard wheelchair in the home and can and does self-propel a lightweight wheelchair. As the requested wheelchair is not deemed medically necessary the accompanying E2611 back cushion does not meet Medicare's LCD: Wheelchair Seating (L33312) coverage criteria and is not medically 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve lightweight wheelchair (CPT code K0003) and general use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware (CPT code E2611), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (procedure code 00300) provided to the enrollee on August 27, 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 diagnosis code C44.319 is not indicated on the list of appropriate diagnosis codes.  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 00300 is "Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified."  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 documentation did not include an anesthesia report to confirm that anesthesia care was given. Per the physician operative report - ""Anesthesia Monitored anesthesia care"; "The patient underwent sedation by the anesthesia team." As no specific anesthesia report was found in the documentation submitted, this procedure cannot be verified.  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 anesthesia services (procedure code 00300) provided to the enrollee on August 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 7,
2020 and billed under code 29823.
You asked the Plan to pay for code 29823. You say that this claim should be paid. The Plan denied your
request. The Plan says while codes 29826 and 29827 were paid, code 29823 is a bundled code and could not be
paid separately. Maximus overturned the Plans denial due to insufficient information regarding the decision.
The Plan requested a reopen and provided additional information. The Plan says that code 29823 denied
correctly based on the Medicare billing guidelines. The Plan says that payment for line 2 is bundled into
payment for line 1 and cannot be paid separately since they have the same end base code of 29805. This is
based on the National Physician Fee Schedule Relative Value File.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, we have
confirmed that code 29823 cannot be paid due to a bundling issue. We note the Plan paid for codes 29826 and
29827 as they were billed correctly. Medicare billing criteria have not been met. Therefore, we decided that the
Plan does not have to pay for physician services provided to the enrollee on October 7, 2020 and billed under
code 29823.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 minutes (99239) rendered by the out-of-network (OON) provider on July 6, 2020.

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 hospital discharge day management; more than 30 minutes (99239) rendered by the out-of-network (OON) provider on July 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan of the head or brain (70450) provided on May 25, 2021.  You asked the Plan to waive the copayment for a CT scan of the head or brain. You say that your annual CT scan should be covered due to your injury. 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 $275 copayment for advanced imaging services when provided at an outpatient hospital.   You have been asked to pay a $108.62 copayment for a CT scan of the head or brain. A CT scan of the head or brain falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 CT scan of the head or brain (70450) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on August 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this enrollee since it is the nursing facilities responsibility to get authorizations for their patients. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 domiciliary or rest home visit (99336) provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on April 22, 2021.

You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that cardiovascular disease screening (blood) tests are defined as "A lipid panel consisting of a total cholesterol, HDL cholesterol and triglyceride. The test is performed after a 12-hour fasting period." Furthermore, "Medicare Part B covers cardiovascular disease screening tests when ordered by the physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals without apparent signs or symptoms of cardiovascular disease. The review has determined that the enrollee does not meet the criteria for this testing. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tetanus vaccine (90471, 90715) provided August 26, 2021.

You asked the Plan to pre-approve the tetanus vaccine. You say that the vaccination should be covered. The Plan denied your request. The Plan says coverage criteria has not been met.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pre-approve a tetanus vaccine (90471, 90715) provided August 26, 2021.

Benefits for the tetanus vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.