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

We decided that the Plan does not have to waive the cost-sharing for outpatient surgical services (64493)
provided on March 18, 2021.
You asked the Plan to waive the cost-sharing for the outpatient surgical services. You say that the services
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the
services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1000 deductible and a $350 copayment which applies to Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
The item or service you asked the Plan to waive the deductible for falls within the Outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has
followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to surgery
services. This cost sharing is a contractual obligation that had not been met at the time the surgical services
were received on March 18, 2021. Therefore, $820.781 has been applied to your deductible.
Since the deductible was met, you have also been asked to pay a 349.63 copayment for the outpatient surgical
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 cost share for outpatient surgical services (64493) provided on
March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that it would benefit the enrollee to go to a SNF. You say that the enrollee is not safe coming home and needs help with transfers. You say that the enrollee is severely de-conditioned from his prolonged hospitalization. The Plan denied your request. The Plan says the enrollee's condition is now stable, and he does not require daily nursing care or daily skilled rehabilitation therapy.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require any services on an inpatient basis, only in a SNF setting. Providing services in a long-term care facility on a part-time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on August 30, 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 must follow Medicare rules. The rules say that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.    We looked at the file and Medicare rules. The file shows that the billing of modifier -25 was not appropriate for the services at issue. 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 office visit rendered on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reimburse an additional amount for the urgent care visit for an urgent care visit (99203) rendered on August 15, 2021.  You asked the Plan to reimburse an additional amount for the urgent care visit for an urgent care visit. You say that you would like a reimbursement of the amount you paid. The Plan denied your request. The Plan says you were reimbursed the correct amount.  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 can receive emergency services from any provider, whether or not the provider is a part of our network. When you receive emergency or urgently needed services from a provider who is not part of our network, you are only responsible for paying your share of the cost, not for the entire cost. You should ask the provider to bill the plan for their share of the cost. If you pay the entire amount yourself at the time you receive the care, you need to ask the Plan to pay you back for their share of the cost. Send the Plan the bill, along with documentation of any payments you have made.   You asked the Plan to reimburse you more for the urgent care visit. The record shows that the Plan is only obligated to reimburse you based on the allowed amount of the service, minus the $25 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 reimburse an additional amount for the urgent care visit for an urgent care visit (99203) rendered on August 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia services (99100) provided on February 16, 2021.  You asked the Plan to pay for special anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable. The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Code 99100 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia services have not been met. Based on this information, we decided that Medicare rules for coverage of special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services (99100) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the autologous blood or component, collection and processing (86891), special pump services (99190 and 99191) and washed red blood cells (P9022) provided on August 18, 2021.  

You asked the Plan to pay for the the autologous blood or component, collection and processing, special pump services (and washed red blood cells. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for these services is included in the payment to the facility.  

The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the the autologous blood or component, collection and processing, special pump services (and washed red blood cells have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. Payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the autologous blood or component, collection and processing (86891), special pump services (99190 and 99191) and washed red blood cells (P9022) provided on August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient hospital transfer.  

You asked the Plan to pre-approve an inpatient hospital transfer. You say that the enrollee requires transfer to the requested facility for management of acute symptoms of his terminal illness. You say that the requested hospital is the only option if the enrollee is discharged, as he is high risk for readmission. You say that the clinical information provided supports the need for the requested transfer. The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care hospital to another for the same level of 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 an inpatient hospital transfer. Our reviewer says that an inpatient hospital transfer is not considered medically reasonable and necessary in this case. Our physician reviewer found the treating physicians wish to transfer the enrollee to the requested hospital to receive Hospice care. Hospice services are covered by traditional, fee-for-service Medicare even when the beneficiary has a Medicare Advantage plan. The acute care hospital where the enrollee is currently located can request hospice services through traditional FFS Medicare.  However, the current request to transfer to another acute inpatient facility to receive the same services that are currently being rendered remains denied because it 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 an inpatient hospital transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital transfer.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure codes 22220 and 76000) provided to the enrollee on May 11, 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 requested service codes are not substantiated in the clinical documentation.  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 22220:  Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical  CPT 76000:  Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time  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 medical records provided indicate that CPT 22551-59 was performed on May 11, 2021. CPT 22220 and CPT 76000 are inclusive to CPT 22551-59 that was performed on May 11, 2021. The medical records provided do not include sufficient documentation to validate billing CPT 22220 or CPT 76000as a distinct, separate service. In this case, the denied codes were performed as part of 22551-59 as a standard of medical/surgical practice and should not be separately reported.  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 (procedure codes 22220 and 76000) provided to the enrollee on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The short-term acute care hospital can provide for all of the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 17, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.     We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on December 16, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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 the laboratory services are not supported in the medical record. Specifically, the documentation submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition states a urine specimen was collected. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services provided by an out-of-network provider on June 14, 2021.  You asked the Plan to pay for the surgery services. You say that the correct primary insurance was not discovered until after the procedure. You say that the provider is not at fault and the claim should be reprocessed to pay accordingly. The Plan denied your request. The Plan says members must receive care from a network provider.  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. Therefore, we decided that the Plan does not have to pay for the surgery services provided by an out-of-network provider on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29 and a core buildup, including any pins when required (D2950) for tooth #29.  You asked the Plan to pre-approve the crown and core buildup. The Plan denied your request. The Plan says a diagnostic x-ray was not submitted showing tooth #29 in its entirety, including the apex. The Plan also says that  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. Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  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. The record shows that the Plan made multiple attempts to request digital quality x-rays but they were unable to get through to the provider's office. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29 and a core buildup, including any pins when required (D2950) for tooth #29.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 11, 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 an appropriate modifier was not 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. In this case, we have confirmed that code 95822
is a column II code to column I code 51875. 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 imaging services provided to the enrollee on May 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the sensory integration (97533) provided on March 17, 2020.

You asked the Plan to pay for the sensory integration. You say that the service provided was medically necessary. The Plan denied your request. The Plan says that experimental or investigational services are not covered.

Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sensory integration have not been met. The record shows that the Plan requested additional medical records, but none were provided. Therefore, we decided that the Plan does not have to pay for the sensory integration (97533) provided on March 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care provided from March 11, 2021, to August 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the evaluation and management services. You say that the services should be covered. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee. The Plan also says that the services were not urgent or emergent in nature.    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 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 subsequent nursing facility care provided from March 11, 2021, to August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder testing rendered on July 15, 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 must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.  We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on July 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on October 2, 2020.  You asked the Plan to waive the copayment for physical therapy. You say that you would like the Plan to pay for this. 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 $40 copayment for outpatient rehabilitation services.   You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation services 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 physical therapy provided by a participating provider on October 2, 2020.