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

 We decided that the Plan has to pay for the anesthetic agent injection (64415) provided on April 5, 2021.  You asked the Plan to pay for the anesthetic agent injection (64415). You say that this charge should not be considered incidental or bundled to the primary service as it was provided for post-operative pain. You say that the additional documentation should be accepted for processing and payment of the claim. The Plan denied your request. The Plan says that this code is included in CPT code 01844 and cannot be separately reimbursed.  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 64415 is injection(s), anesthetic agent(s) and/or steroid; brachial plexus.  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 anesthetic agent injection (64415). Our reviewer says that the documentation submitted was reviewed and does meet the criteria for coverage. Our reviewer found that the anesthesia report documents "post op pain management" and this service can be reported separately when it meets certain criteria. Post operative pain management is covered separately when post op pain block is separate and distinct from the anesthesia used to perform the surgery. Since anesthesia services document post op pain, this service should be covered.  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 anesthetic agent injection (64415) have been met. Therefore, we decided that the Plan has to pay for the anesthetic agent injection (64415) provided on April 5, 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 home visit for the evaluation and management of an established patient (CPT code 99350) provided to the enrollee on March 3, 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 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. In this case, we have confirmed that code 99350 is a column II code to column I code 97163. 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 home visit for the evaluation and management of an established patient (CPT code 99350) provided to the enrollee on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for miscellaneous durable medical equipment (E1399) provided June 24, 2021.  You asked the Plan to pay for the durable medical equipment. You say that this was the only place that was able to ship to the scooter in three days. The Plan denied your request. The Plan says the items were obtained from a provider who is not under contract with the health Plan, is not certified for Medicare and was not authorized with the Plan.  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 miscellaneous durable medical equipment (E1399) provided June 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after January 31, 2022.  You asked the Plan to pre-approve SNF care. You say that you need to be much stronger before you are discharged from the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  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 continued skilled nursing facility (SNF) care after January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgical services provided from February 11, 2021, to April 1, 2021.  You asked the Plan to waive the copayment 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers.     You have been asked to pay a $1,366.32 copayment for seven outpatient surgical service visits. Outpatient surgical services fall within the Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgical services provided from February 11, 2021, to April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 23, 2021.  You asked the Plan to pay for the dental service. You say that your regular dentist advised you needed a root canal. You say that you were referred to an endodontist. You say that the endodontist determined a root canal could not be done. You also say that you feel that this should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.  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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded.     The record shows that the Plan paid for a limited oral evaluation that you received on April 15, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gastrostomy tube replacement (43762) provided on February 8, 2021.  You asked the Plan to pay for the gastrostomy tube replacement (43762). The Plan denied your request. The Plan says the billed service 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 43762 is replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract.    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 gastrostomy tube replacement (43762). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the documentation does not include evidence of a gastrostomy tube, therefore 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 gastrostomy tube replacement (43762) have not been met. Therefore, we decided that the Plan does not have to pay for the gastrostomy tube replacement (43762) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services performed on July 29, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that you were not informed of any charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 must pay a $5 copayment for diagnostic lab services.   You have been asked to pay a $5 copayment for the laboratory services. The laboratory services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services performed on July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 7, 2021.  You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged 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 must pay a $110 copayment for ultrasounds.   You have been asked to pay the allowed amount of $98.62, which is less than the $110 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the requested services. You say that you cannot prick your fingers because it makes you sick. The Plan denied your request. The Plan says you do not meet the coverage criteria.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the umbilical hernia repair (49585) provided on June 29, 2021.  You asked the Plan to pay for the umbilical hernia repair (49585). You say that a separate incision was made to repair the hernia and the codes do not bundle. You say that the records support the separate billing. The Plan denied your request. The Plan says the requested procedure code 49585 would be considered inclusive to procedure code 44204-AS.   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 49585 is repair umbilical hernia, age 5 years or older; reducible. 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 umbilical hernia repair (49585). Our reviewer says that this does not meet the criteria for coverage. Our reviewer found the medical records submitted do not include sufficient documentation that the hernia repair was a distinct separate procedure, therefore 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 umbilical hernia repair (49585) have not been met. Therefore, we decided that the Plan does not have to pay for the umbilical hernia repair (49585) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone graft; mandible (21215 x 2), bone graft; nasal, maxillary or malar areas (21210 x 2), panoramic x-ray (70355), and oral surgical splint (21085 x 11).  You asked the Plan to pre-approve the dental services. You say that the enrollee qualifies for medical necessity under the plan's orthognathic medical policy guidelines which excludes the patient from plan's dental exclusion. The Plan denied your request. The Plan says the requested services do not meet the criteria for coverage.  Medicare generally does not cover dental services. The Plan follows the same rules.   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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the provided documentation indicates that the bone grafts are to be placed to increase the volume of the alveolar process to support dental prostheses. The reviewer also found that the orthognathic medical policy guidelines do not apply since the alveolar bone resorption was not related to skeletal deformity. Therefore, the reviewer found that the requested services are dental in nature and are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a bone graft; mandible (21215 x 2), bone graft; nasal, maxillary or malar areas (21210 x 2), panoramic x-ray (70355), and oral surgical splint (21085 x 11).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a durolane injection provided on April 16,
2021.
You asked the Plan to waive the coinsurance for the injection. You say that you were informed that the
procedure was covered. The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for Part B drugs, including injectable pain relief drugs.
You have been asked to pay $397.92, which is 20% of the allowed amount for the injection ($1989.60 allowed
amount x 20% coinsurance = $397.92). Please note that while the service is considered covered, the
coinsurance still applies. The injection falls within the Medicare Part B Prescription Drugs benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for a durolane injection provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the crown (D2740), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on August 4, 2021.  You asked the Plan to reimburse you for the dental services. You say that you were advised by 2 different plan representatives that although the dentist was out of network with Medicare, you would still be reimbursed 50% up to $1,000. The Plan denied your request. The Plan says that the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a provider that has opted out of Medicare.  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, payment cannot be made to providers that have opted out of Medicare. Additionally, the file shows that the plan representative advised that if the provider has opted out of Medicare completely, the claim would not process. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided to the enrollee on March 1, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  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 drug testing have not been met. CPT code G0480 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on March 1, 2021, and received by the on March 22, 2021. Of note, the patient resides in Alabama (AL) and the billing laboratory is located in Tennessee (TN); therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided to the enrollee on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cystourethroscopy (52356) provided on March 22, 2021.  You asked the Plan to pay for the cystourethroscopy (52356). You say that the operative report supports procedure code 52356, and the claim should be reprocessed. The Plan denied your request. The Plan says the billed service 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 52356 is cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type).    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 cystourethroscopy (52356). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the procedure report describes cystoscopy, retrograde pyelogram was performed. The documentation does not support CPT code 52356, and a more appropriate code should be reported for the services 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 cystourethroscopy (52356) have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy (52356) provided on March 22, 2021.