Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on May 16, 2019, through May 20, 2019 and billed with Diagnosis Related Group (DRG) 871.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support DRG 871 with a primary diagnosis of sepsis.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient hospital services. Our reviewer says that the review has determined that the documentation did not support DRG 871 with  diagnosis code A41.9. Our physician reviewer found the documentation was inconsistent regarding a diagnosis of sepsis and supporting medical record documentation was not found within the record. Sepsis was not a diagnosis on the discharge summary.  He presented to the ED from a rehab facility with increased confusion, hallucinations, and weakness on the right side.  There was no evidence of significant physiologic instability.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on May 16, 2019, through May 20, 2019 and billed with Diagnosis Related Group (DRG) 871.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (44640) provided July 23, 2021.  You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is inclusive to another code billed and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 44640 is not supported in the medical record. Specifically, CPT code 44640 is considered inclusive to procedure code 44625 which was also billed on the same claim. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (44640) provided July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the audiologist visit provided on August 31, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the audiologist visit. You say that you did not know you needed a referral from your primary care doctor to see the audiologist. You say there was miscommunication due to the language barrier. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the audiologist visit provided on August 31, 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 transportation of portable x-ray equipment rendered on July 20, 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 R0070 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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.  We find that CPT code R0070 is not supported in the medical record. Specifically, the transportation code was not billed with a required set-up code. 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 transportation of portable x-ray equipment rendered on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity. 

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (CPT code 99285) provided to the enrollee on June 29, 2021.  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 covered.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. An emergency department service E/M is not separately reportable with critical care services when performed on the same day by the same provider. A review of the documentation indicates the providers reported on the current and related claim are of the same group and specialty, and the emergency department E/M was reported for the same calendar date as the critical care services. Therefore, we decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (CPT code 99285) provided to the enrollee on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment genetic screening testing (CPT code 81442-XS) provided to the enrollee on April 6, 2021.

You asked the Plan to pay for the testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not indicate how the test results will assist in managing the enrollee's condition.

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 enrollee's primary care physician did not order cardiovascular genomic testing for this enrollee. The Plan states the provider said the most recent visit was on February 11, 2021, for an annual physical. The Plan states they confirmed with the enrollee that they received a genetic test kit from this provider via mail and returned via mail to a laboratory. Therefore, the genetic testing was initiated by this provider and POS 81 is not applicable. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment genetic screening testing (CPT code 81442-XS) provided to the enrollee on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoulder surgical procedure provided on July 12, 2021, billed with code 29999.  You asked the Plan to pay for the services as billed. You say that the code 29999 should be paid as this represents a procedure that does not have a specific code. The Plan denied your request. The Plan says the use of the unlisted code is not supported 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 CPT code.  In this case, the CPT Code Manual definition of code 29999 is unlisted procedure, arthroscopy.  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 as billed. Our reviewer says that the billed code 29999 is not supported. Our reviewer found the provider is reporting CPT 29999 for microfracture, shoulder, as there is no procedure code to report for this service. However, the documentation does not include additional information to substantiate that this procedure would not be inclusive to the more comprehensive procedure performed. The operative report does not confirm microfracture, shoulder as a separate or increased procedural service.   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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder surgical procedure provided on July 12, 2021, billed with code 29999.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the walking boot rendered on June 12, 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 L4361 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 L4361 is walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf.  We find that CPT code L4361 is not supported in the medical record. Specifically, there is no documentation that a pneumatic and/or vacuum walking boot was dispensed. 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 walking boot rendered on June 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided on April 13, 2021.  You asked the Plan to pay for the additional supplies and materials. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.    We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 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 services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal 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 the laboratory services rendered on July 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure (52000) provided on May 28, 2021.  You asked the Plan to waive the copayment for the cystourethroscopy. You say that you believed this service was supposed to have a lesser copayment. The Plan denied your request. The Plan says this copayment was assessed in accordance with your contract. Outpatient surgery or other services provided at an ambulatory surgical center require a $195 copayment.  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 $195 copayment for Medicare-covered surgery or other services provided at an ambulatory surgical center.   You have been asked to pay a $195 copayment for the cystourethroscopy. The cystourethroscopy falls within the Medicare-covered surgery or other services provided at an ambulatory surgical center 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 the cystourethroscopy procedure (52000) provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 27, 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 services are not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from December 30, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of December 30, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of December 30, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care with minimal improvement; however, their functional improvement had plateaued by December 30, 2021, and the enrollee did not require any further inpatient skilled rehabilitation services. The enrollee could be discharged to a lower level of care for further services. As of December 30, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from December 30, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the devitalized tissue removal provided on June 17, 2021, billed with code 97598.

You asked the Plan to pay for the billed code 97598. You say that this should be paid. The Plan denied your request. The Plan says 97598 is a Column 2 code in relation to 11042, and no modifier was used.

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 97598 is a column II code to column I code 11042. 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 devitalized tissue removal provided on June 17, 2021, billed with code 97598.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten (10) additional speech therapy (ST) visits (92507).  You asked the Plan to pre-approve additional ST visits. You say that the requested additional ST visits are medically necessary. The Plan denied your request. The Plan says the requested additional ST visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   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 additional ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee appears to have improved with therapy to the point that most therapy goals have been met and recent therapy over the past month has shown no significant further progress. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of his homework activities appears appropriate at this point.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional speech therapy (ST) visits (92507).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic services provided on July 17, 2021 to August 9, 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 diagnostic services provided on July 17, 2021 to August 9, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an endoscopy (43239) provided on August 4, 2021.  You asked the Plan to waive the copayment for an endoscopy. You say that you were unaware of the copayment and you should not be held responsible for it. The Plan denied your request. The Plan says the copayment was 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 $250 copayment for outpatient surgery.   You have been asked to pay a $250 copayment for an endoscopy. The service at issue falls within the outpatient surgery 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 an endoscopy (43239) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient office visit (99215) provided February 9, 2021.  You asked the Plan to waive the copayment for the office visit. You say that you reached your out of pocket on 03/16/2021. The Plan had changed the claim from the $752.50 that you had paid to a different amount. Now it shows adjusted and is now including the $752.50 in your total. The Plan denied your request. The Plan says this claim was processed with the correct copayment 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 $25 copayment for specialist's office visits.   You have been asked to pay $25 copayment for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits 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 the outpatient office visit (99215) provided February 9, 2021.