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

 We decided that the Plan does not have to pay for out-of-network physician services provided on July 30, 2021  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 out-of-network physician services provided on July 30, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic services received on November 18, 2020.  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 this was not billed correctly.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received on November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computer-assisted surgical orthopedic procedure (0055T) provided on May 27, 2021.  You asked the Plan to pay for a computer-assisted surgical orthopedic procedure. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.    The Plan must follow Medicare rules. Medicare rules say that 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.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a computer-assisted surgical orthopedic procedure have not been met. Specifically, no medical documentation has been provided to confirm that Medicare coverage criteria for the procedure at issue have been met. Therefore, we decided that the Plan does not have to pay for a computer-assisted surgical orthopedic procedure (0055T) provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for sedation services (99153) provided on March 16, 2021.  You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid 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 99153 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telephone evaluation and management (EM) service provided on June 1, 2021, billed with code 99442.  You asked the Plan to pay for the EM service as billed. You say that you do not know what this code would be considered to be bundled with and believe it should be paid. The Plan denied your request. The Plan says this was billed within 7 days of another EM service, meaning it is not correctly 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, the CPT Code Manual definition of code 99442 is telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.  We find that CPT code 99442 is not supported in the medical record. Specifically, the record does not support that this was a telephone EM service as it appears that audio and visual communication was included. In addition, the services were rendered 7 days after a prior EM visit. This means that the billed code is not valid for the service rendered. Based on this information, we decided that Medicare rules for coverage of the EM service as billed have not been met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management (EM) service provided on June 1, 2021, billed with code 99442.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for X-rays provided on June 2, 2021.  You asked the Plan to waive the copayment for the X-rays. You say that you feel the copayment is too high. 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 $50 copayment for X-rays received in an outpatient hospital facility. If multiple tests of the same type are performed in the same day, one copayment will apply.   You have been asked to pay one $50 copayment for five X-rays. X-rays 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 X-rays provided on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve destruction by neurolytic agent.  You asked the Plan to pre-approve destruction by neurolytic agent. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and necessary when specific criteria are met.  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 destruction by neurolytic agent. Our reviewer says that the services are not medically necessary. Our physician reviewer found the degree and duartion of the pain relief from the diagnostic blocks is not documented. This does not meet the criteria requirements of the LCD and NCD. Therefore, the request is deemed not medically reasonable or 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 destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablations (RFA).  You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary when specific criteria are met.   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 RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires that diagnostic medial branch blocks (MBBs) be performed if more than 2 years has passed since the RFA. Therefore, a repeat diagnostic set of MBBs, is required here. At this time, the request for RFA is considered not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestlye Libre continuous glucose monitor and supplies for the enrollee.  You asked the Plan to pre-approve a CGM and supplies. You say that the member get injections 3 times per day. The Plan denied your request. The Plan says that the enrollee does not receive at least 3 insulin injections per day.  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM and supplies. Our reviewer says that a CGM and supplies are not medically reasonable and necessary for the enrollee.   The record indicates that the enrollee has diabetes and uses insulin once daily. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a CGM and supplies.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestlye Libre continuous glucose monitor and supplies for the enrollee.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on July 26, 2021.  You asked the Plan to waive the copayment for an emergency room visit. You say that you feel you were needlessly sent to the ER after speaking with a staff member from the office of your primary care physician (PCP). You say the treating doctor at the ER stated you did not need intravenous (IV) antibiotics and prescribed an oral antibiotic. You feel you should not have been sent to the ER in the first place and should not have to pay a copayment for the service. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan reviewed the medical records and confirmed you were referred by your PCP for IV antibiotics to treat a urinary tract infection (UTI).    The Plan says the records indicate an evaluation and subsequent treatment of the UTI was provided at the ER, where it was determined you could be treated with oral antibiotics instead. The Plan states quality of care or service concerns go through a comprehensive evaluation process, but the process does not include waiving copayments for services rendered, regardless of the outcome of that evaluation.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency Care.   You have been asked to pay a $90 copayment for an emergency room visit. The services at issue fall within the Emergency 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 copayment for an emergency room (ER) visit provided on July 26, 2021.   Your complaint about quality of service concerns is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints. The Plan indicated you were advised a separate letter would be issued to address your concerns. Please contact the Plan for further information about this grievance.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits.  You asked the Plan to pre-approve 4 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 4 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a telehealth visit received on May 25, 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 this was billed with an incorrect date of service.  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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter."  We find that CPT code 99214 is not supported in the medical record. Specifically, an incorrect place of service was used to report these services. The appropriate place of service would be 02 in this case. 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 a telehealth visit received on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on June 6, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 computed tomography (CT) scan rendered on June 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder Triage testing (81479) provided on May 18, 2021.  You asked the Plan to pay for the CxBladder Triage testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this testing is not covered for screening purposes.  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, the CxBladder Triage testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any clinical information to determine why this testing was ordered or how it will influence the treatment of the member's condition. Therefore, we decided that the Plan does not have to pay for the CxBladder Triage testing (81479) provided on May 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility services provided from March 13, 2020, to March 30, 2020 billed with code IIEB1.  You asked the Plan to pay for the SNF stay as billed. You say that you do not dispute the reduction of functional score nor the removal of chronic obstructive pulmonary disease (COPD) from this claim. However, you feel that the NTA case-mix group was correct since inflammatory bowel disease is supported. The Plan denied your request. The Plan says the NTA case-mix group would be reduced since inflammatory bowel disease is also not supported.  The Plan follows Medicare rules. Medicare rules say that SNF payment is made based on the calculated HIPPS code, which is formulated from, among other things, reported active diagnoses for the SNF stay. Active diagnoses must meet certain criteria to be included for billing/payment purposes.  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 SNF stay as billed. Our reviewer says that the reported diagnosis for inflammatory bowel disease is not supported by the record. Our physician reviewer found the enrollee is an 84-year-old man with a history of rectal cancer, endocarditis, and anemia. On 2/7/2020, the enrollee's assessment included C. difficile colitis. It is noted that the enrollee had rectal bleeding. The clinical documentation in the case file does not include diagnoses of Crohn's disease, ulcerative colitis, or other inflammatory bowel disease as an active diagnosis.  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 SNF stay as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services provided from March 13, 2020, to March 30, 2020 billed with code IIEB1.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on October 1, 2020.  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 a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 77002) provided to the enrollee on March 15, 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 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 77002 is a column II code to column I code 72132. 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 (procedure code 77002) provided to the enrollee on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the primary care office visit you had on May 13, 2021.  You asked the Plan to waive the copayment for the primary care office visit. You say that this was your annual wellness visit, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for primary care visits.   Your Evidence of Coverage says that an annual wellness visit includes services to develop or update a personalized prevention plan based on your current health and risk factors. We looked at the medical records from this date of service to determine what type of visit you had.  According to those records, this was not an annual wellness visit.  Rather, the records show that you presented to the doctor's office to follow-up on your hypothyroidism and high cholesterol, as well as increased a1c levels. There is nothing in the medical records to indicate that this visit was performed to develop or update a personalized prevention plan. That is why you have been asked to pay a $10 copayment for the primary care office visit. 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 primary care office visit you had on May 13, 2021.