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

We decided that the Plan does not have to pay for the nursing facility care provided on June 15, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to obtain the proper authorization. The Plan denied your request. The Plan says the claim denied correctly.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on June 15, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

participating 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 a non-participating 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 office visit provided on April 1, 2021 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on January 10, 2021.
You asked the Plan to pay for the services provided. 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.
We looked at the file and the rules. CPT code 704544 was billed with code 70551. We find that the services at
issue are separately payable when billed with an appropriate modifier. The claim provided does not show that
the services were billed with a payable modifier. Based on this information, we decided that Medicare rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services
provided on January 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90837) provided on November 3, 2020.

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because this service was denied in error. The Plan denied your request. The Plan says that the claim was not billed with an appropriate diagnosis code for the CPT code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 90837 is supported in the record. Specifically, per the LCA, the diagnosis code billed is appropriate for CPT code 90837. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) provided on November 3, 2020.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care represented by code 99223 provided on February 7, 2021.

You asked the Plan to pay for code 99223. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99223.

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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 

We find that CPT code 99223 is not supported in the medical record. Specifically, the medical records do not include a comprehensive history, a comprehensive examination, and medical decision making of high complexity. Based on this information, we decided that Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care represented by code 99223 provided on February 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on May 14, 2021.
You asked the Plan to pay for the ophthalmological services (92004), refraction (92015), and visual field examination (92083). You say that the provider told you everything was ok with insurance. The Plan denied your request. The Plan says there was no authorization for the out-of-network services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the preferred provider. We looked at the file and the Plan's rules. You did not use the preferred provider and did not have authorization for the out-of-network services. Based on this information, we decided that the Plan's rules for coverage of the ophthalmological services (92004), refraction (92015), and visual field examination (92083) have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a heavy-duty walker (E0147), provided on March 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a heavy-duty walker. You say that the item should be covered. The Plan denied your request. The Plan says there is no authorization on file for these services nor was an attempt made to obtain a prior authorization.

Medicare rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. The contract with the Plan says that prior authorization is required for all durable medical equipment (DME) items with a purchase price greater than $500 or $38.50 per month, if rented. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker have not been met.

The Plan requires prior authorization for all durable medical equipment (DME) items with a purchase price greater than $500 or $38.50 per month, if rented. Therefore, we decided that the Plan does not have to pay for a heavy-duty walker (E0147), provided on March 14, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and care
provided April 24, 2021, to April 30, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the treatment provided
was unacceptable and you don't believe you should be responsible for any cost. 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 $175
copayment per day for days 1-5 of inpatient hospital care.
You have been asked to pay a total of $875 ($175 copayment x 5 days = $875) for the inpatient hospital stay.
This inpatient hospital stay falls within the Inpatient hospital 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 the inpatient hospital admission and care provided April 24, 2021, to April 30,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 15, 2021, by an out-of-network
provider.
You asked the Plan to pay for debridement (11042, 11043, 11044). You say that the services were urgently
needed. The Plan denied your request. The Plan says prior authorization was not requested.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for wound care provided on May 15, 2021, by an out-of-network
provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on April 13, 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 separately payable.
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the
same specialty must bill and be paid as though they were a single physician.
We looked at the file and Medicare rules. The file shows that the Plan paid for procedure code 99232
(subsequent hospital care) for the same date of service billed by a physician within the same group practice.
Code 99223 (initial hospital care) is not separately payable. Therefore, we decided that the Plan does not have
to pay for the initial hospital care rendered on April 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93000) provided on February 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 93000 has a bundled relationship with code 93228 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (93000) provided on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (Select MDx/Confirm MDx) provided to the enrollee on January 22, 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 screening services without a valid medical diagnosis related to the health of the patient are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found without info on the previous biopsy, the claim must remain denied. There is not enough clinical information 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (Select MDx/Confirm MDx) provided to the enrollee on January 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a sleep study. You say that you would like an out-of-network physician to provide these services. The Plan denied your request. The Plan says there are in-network physicians available to provide these services.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on April 9 to May 21, 2021, by an out-of-network provider.
You asked the Plan to pay for outpatient mental health services. You say that you have been with the out-of-network provider for 5 years. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on April 9 to May 21, 2021, by an out-of-network provider
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy provided on May 7, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a preventative colonoscopy and you should not be responsible for the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether the services provided were preventative or diagnostic. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy provided on May 7, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional OT visits.
You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT is medically
necessary. The Plan denied your request. The Plan says additional OT is not medically necessary.
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 ten (10) additional OT 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 that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a
qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further 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 ten (10) additional OT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services rendered from January 11, 2021 to January 21, 2021.
You asked the Plan to pay for these services. You say that you have included an itemized bill. The Plan denied your request. The Plan says an itemized bill is needed for claim reconsideration.
The Plan must follow Medicare rules. Medicare rules say that the provider or supplier has 14 days to submit necessary documentation for an appeal request. We looked at the file and Medicare rules. The file shows that the Plan has not received an itemized bill for these services from the provider. The documentation submitted is a Claims Summary, not an itemized bill, and states "This is not a bill" on the form. 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 behavioral health services rendered from January 11, 2021 to January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on October 21, 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 procedure codes 64493, 64494, and 64495 are 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 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level. The definition of code 64494 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure). The definition of code 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). We find that procedure codes 64493, 64494, and 64495 are not supported in the medical record. Specifically, the submitted records do not contain the name of the servicing provider to support primary procedure code 64493. Given that the primary procedure code is not supported, add-on codes 64494 and 64495 are not supported. 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 pain management services rendered on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ophthalmology visit with refraction and ophthalmoscopy you had on April 6, 2021.
You asked the Plan to reduce the copayment for the ophthalmology visit. You say that you thought you only had a $20 copayment for an annual routine eye exam. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says this was not a routine eye exam, but a medical eye exam.
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 exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $40 copayment for the ophthalmology visit. The records from this visit show that you were evaluated for cataracts, dry eye syndrome, and vitreous degeneration of the right eye.
These are medical conditions and evaluation of them is not part of a routine eye exam. That is why the ophthalmology visit falls within the exams to diagnose and treat diseases and conditions of the eye 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 reduce the copayment for the ophthalmology visit with refraction and ophthalmoscopy you had on April 6, 2021.