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

 We decided that the Plan has to pay for hospital services provided on April 18, 2020, and April 19, 2020.  You asked the Plan to pay for hospital services provided on April 18, 2020, and April 19, 2020. The Plan denied your request. The Plan says that the member does not have active hospice status and services are hospice related.  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. Specifically, the Plan has not provided us with proof of Hospice enrollment and disenrollment (i.e., CMS Common Working File). Therefore, we decided that the Plan has to pay for hospital services provided on April 18, 2020, and April 19, 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 waive the copayment for inpatient hospital services provided from June 22, 2021, to June 28, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were discharged too early from a previous stay and should not be charged for the second stay. 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 $390 per day for days 1-5 and $0 per day after day 5 for each inpatient stay.   The file shows that you were in the hospital from June 22, 2021, to June 28, 2021. Therefore, you have been asked to pay $390 per day for the first 5 days of inpatient hospital services. The total for your stay is $1950 ($390 copayment x 5 days = $1950). The inpatient hospital services fall 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 inpatient hospital services provided from June 22, 2021, to June 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health skilled care visits.  You asked the Plan to pre-approve home health care. You say that the enrollee needs this care and cannot live without it. The Plan denied your request. The Plan says the denial of authorization for additional home health visits is correct.  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 home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested additional home health visits. Our physician reviewer found the enrollee does not require additional skilled nursing services to effectively provide treatment, care, or services in order to improve the enrollee's condition or perform a maintenance program. The enrollee has been medically stable with no recent exacerbations of medical problems or hospitalizations.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled care visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on October 4, 2021.

You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were 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 diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Disposable drug delivery system (A4305) supplies for
maintenance of non-insulin drug infusion catheter, per week (list drugs separately) (A4221) sterile water, saline
and/or dextrose, diluent/flush, 10 ml (A4216) infusion supplies for external drug infusion pump, per cassette or
bag (list drugs separately) (A4222) provided January 4, 2020 to January 6, 2020.
You asked the Plan to pay for the medical supplies. You say that new medical records were submitted for this
appeal and consist of a progress note and delivery ticket for the service date. The Plan denied your request. The
Plan says the billed services was not supported in the medical records.
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 enrollee used the equipment in the facility during inpatient hospitalization. Payment for this
service would have been included under the facility claim. Payment for this service is the responsibility of the
facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for
coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay
for Disposable drug delivery system (A4305) supplies for maintenance of non-insulin drug infusion catheter,
per week (list drugs separately) (A4221) sterile water, saline and/or dextrose, diluent/flush, 10 ml (A4216)
infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222) provided
January 4, 2020 to January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on June 8, 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. 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 01480 is anesthesia for open procedures on bones of lower leg, ankle, and foot; not otherwise specified. 

We find that CPT code 01480 is not supported in the medical record. Specifically, there is no documentation of anesthesia for open procedures of the bones of lower leg, ankle, and foot. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.

Billed procedure code 99140 (emergency anesthesia) has a status indicator of B and no separate Medicare payment.

Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diabetic shoes provided by a network
provider on September 29, 2021.
You asked the Plan to waive the copayment for the diabetic shoes. You say that you should not be responsible
for the copayment because you have not paid a copayment in the past for diabetic shoes. The Plan denied your
request. The Plan says you have been asked to pay 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 $10
copayment for Medicare-covered therapeutic custom-molded shoes and inserts.
You have been asked to pay a $10 copayment for the diabetic shoes. The diabetic shoes fall within the
"Diabetes self-management training, diabetic 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 diabetic shoes provided by a network provider on September 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transportation provided on September 27, 2021.

You asked the Plan to pay for air ambulance. You say that the air ambulance was required for advanced airway management and ventilator support which was not available on the ground ambulance. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because ground transportation to the destination hospital would have been appropriate.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 air ambulance. Our reviewer says that this air ambulance transportation does not meet criteria for payment. Our physician reviewer found the documentation does not support that the enrollee's condition was such that the time needed to transport the enrollee by ground - or the instability of transport by ground - posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Ground ambulance had ventilator support and appropriate staff, and would have been quicker to reach the destination hospital. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance transportation provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the intracardiac electrophysiologic 3-dimensional mapping (93613),
comprehensive electrophysiologic evaluation (93622) and programmed stimulation and pacing after
intravenous drug infusion (93623). We decided that the Plan does not have to pay for comprehensive
electrophysiologic evaluation (93620).
You asked the Plan to pay for the intracardiac electrophysiologic 3-dimensional mapping (93613),
comprehensive electrophysiologic evaluation (93622) and programmed stimulation and pacing after
intravenous drug infusion (93623). You say that you would like reconsideration based on the records
submitted. The Plan says that an edit exists between CPT codes 93620 and 93655.
We decided that the Plan has to pay for the intracardiac electrophysiologic 3-dimensional mapping
(93613), comprehensive electrophysiologic evaluation (93622) and programmed stimulation and pacing
after intravenous drug infusion (93623).
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent
efforts to gather and forward information to the Independent Review Entity (IRE).
We looked at your request, the file and Medicare rules. Based on this information we have determined that
Medicare criteria for coverage have been met. Specifically, the Plan has not forwarded any evidence as to why
these services were denied. It is the burden of the Health Plan to substantiate their denial with evidence. In this
case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the
Plan has to pay for the intracardiac electrophysiologic 3-dimensional mapping (93613), comprehensive
electrophysiologic evaluation (93622) and programmed stimulation and pacing after intravenous drug infusion
(93623).
We also decided that the Plan does not have to pay for comprehensive electrophysiologic evaluation
(93620).
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly.
We looked at your request, the file and Medicare rules. Based on this information we have determined that
Medicare criteria for coverage have not been met. Specifically, and edit exists between CPT codes 93620 and
93655. This code pair does not allow for the use of a modifier to bypass the edit. CPT code 93620 is not
separately payable. Therefore, we decided that the Plan does not have to pay for comprehensive
electrophysiologic evaluation (93620).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 28, 2021, by an OON
provider.

You asked the Plan to pay for the laboratory services. You say that the physician sent the test to your lab. The
Plan denied your request. The Plan says the referring physician and the provider for services are out-of-network
providers. The services provided were not urgent or emergent.

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 laboratory services provided on July 28, 2021, by
an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90853) provided on June 16, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were 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 CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90853) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH) testing (code 88120) provided to the enrollee on May 5, 2021.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says this testing is not covered as a screening and without presence of confirmed disease.

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. This testing was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH) testing (code 88120) provided to the enrollee on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided October 14, 2021.  You asked the Plan to pay for the bitewing x-rays and 2D oral/facial photographs. You say that you were told the x-rays were covered and there was not mention of a limit. The Plan denied your request. The Plan says you have exceeded the frequency limit for the bitewing x-rays and the 2D photographs are not covered.  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. The Plan covers the bitewing x-rays once per plan year.   We looked at the file and Medicare rules. The Plan provide documentation showing that bitewing x-rays were previously covered on May 10, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the 2D oral/facial photographs are not among those covered services. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diarrhea pathogen panel provided on July 24, 2021.
You asked the Plan to pay for the diarrhea pathogen panel. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says this claim was not billed with an
appropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the diarrhea pathogen panel have not been met. Specifically, this claim was billed with the
laboratory place of service code while the records indicate that the member's face-to-face service was rendered
in an office setting. Therefore, we decided that the Plan does not have to pay for the diarrhea pathogen panel
provided on July 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81201, 81295, 81298, 81317, 81403, 81404, 81405, and 81406) provided to the enrollee on August 9, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are 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 laboratory services have not been met. 

Review of the available clinical case notes and records presented for an appeal of molecular cancer genomics (CGx) testing has been completed. After reassessing the entire situation, the result is that the initial denial is upheld. The enrollee had molecular cancer genomics (CGx) testing on August 9, 2021. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. 

Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 81432 and 81295, 81432 and 81298. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81201, 81295, 81298, 81317, 81403, 81404, 81405, and 81406) provided to the enrollee on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH) testing (code
88120) provided to the enrollee on May 17, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says this testing was ordered as a screening which is not covered by Medicare.
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. This testing was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for Fluorescence in situ Hybridization (FISH) testing (code 88120) provided to the
enrollee on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (CPT code 99231) provided to the enrollee on May 18, 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 99231 and 99223. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (CPT code 99231) provided to the enrollee on May 18, 2021.