Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic testing (87491, 87529, 87556, 87563, 87640, 87653, 87661, 87798, G0480) provided on January 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for diagnostic testing. You say that the referring physician ordered specialized testing for this patient and forwarded the tests directly to the provider. you also say that this provider only performs the testing services and does not have direct patient contact. The Plan denied your request. The Plan says this provider is a non-network provider who does not work with the member's health plan, and the member was referred by a provider who also does not work with the member's plan. The Plan also says that the member's primary care physician did not refer for 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 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 diagnostic testing (87491, 87529, 87556, 87563, 87640, 87653, 87661, 87798, G0480) provided on January 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 6, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee 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 must 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 services provided to the enrollee on August 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 7, 2021 to May 9, 2021.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the provider billed the claims without first submitting the required home health aide reports on the 0023-revenue code and provider has not met criteria necessary for home health service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 7, 2021 to May 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing of the KRAS, BRAF and EGFR genes (81275, 81210, 81235) provided on June 22, 2021.

You asked the Plan to pay for the genetic testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says the member declined treatment and the tests performed are not beneficial in this type of cancer.

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 genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found KRAS/BRAF/EGFR testing is not considered a standard of care in patient's with head and neck cancer. Molecular profiling is not supported by the NCCN Guidelines for these types of cancer. 

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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing of the KRAS, BRAF and EGFR genes (81275, 81210, 81235) provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on September 1, 2021. 
 
You asked the Plan to pay for the resin-based composite. You say that your debit for $122 was cashed on September 1, 2021. You also say that you would either like to be refunded or given a credit for this charge. The Plan denied your request. The Plan says this procedure is not a benefit under the dental plan.

 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2331) provided on September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services rendered on October 7, 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 code 95861 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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas.  We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documentation of needle electromyography of two extremities. 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 testing services rendered on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the implantable device programming evaluation you received from a cardiologist on August 20, 2021.  You asked the Plan to waive the copayment for the implantable device programming evaluation. You say that the doctor could have received the results of this evaluation from your medical center. Instead, you were required to come in and have the device checked in the office. You do not think you should have to pay a copayment for this because the doctor could have gotten the information elsewhere. 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 $45 copayment for medical care with a specialty physician.   You have been asked to pay a $45 copayment for the implantable device programming evaluation. This copayment applies regardless of the reason why you went to the cardiologist's office. 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 implantable device programming evaluation you received from a cardiologist on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 11, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the dialysis center is responsible for laboratory services that are related to the treatment of end-stage renal disease (ESRD).  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that the denied codes are not supported in the medical record. Specifically, the records clearly show that these laboratory services were related to the treatment of end-stage renal disease (ESRD). Therefore, these services cannot be reported separately by the laboratory, and are the responsibility of the dialysis center. 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 provided to the enrollee on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the psychiatric hospitalization provided from August 20, 2021, to August 30, 2021.

  You asked the Plan to pay for the psychiatric hospitalization. You say that the admission was medically necessary. The Plan denied your request. The Plan says that the requested inpatient admission was not reasonable and necessary.  

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 
  
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 psychiatric hospitalization. Our reviewer says that the psychiatric hospitalization was medically reasonable and necessary for the enrollee. Our physician reviewer found it was expected that the enrollee would improve within a reasonable period of time as he did have dangerousness to self but not others. The enrollee had auditory and visual hallucinations, but no delusions. It was medically reasonable and necessary to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Our reviewer found that active treatment was taking place and the services were expected to improve the enrollee's condition or were for the purpose of diagnosis. The record does not include an individualized treatment plan, but the entire record is not present. Our physician reviewer also found that the services were supervised and evaluated by a physician. The Plan's denial of inpatient psychiatric services is inappropriate.  

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 psychiatric hospitalization have been met. Therefore, we decided that the Plan has to pay for the psychiatric hospitalization provided from August 20, 2021, to August 30, 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services (A0382) provided to the enrollee on April 17, 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 Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on April 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services (A0382) provided to the enrollee on April 17, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on August 5, 2021.  You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. 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 $110 copayment for each covered emergency room visit.   Review of the file shows that you received ER services on August 5, 2021. You have been asked to pay a $110 copayment for these services. These services fall within the covered emergency room visit 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 emergency room (ER) services rendered on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing exam rendered on August 25, 2021.  You asked the Plan to pay for these services. You say that this should be covered without a copayment. 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 $40 copayment for a Medicare-covered diagnostic hearing exam.   Review of the file shows that you received a hearing exam on August 25, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered diagnostic hearing exam 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 pay for the hearing exam rendered on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the psychotherapy services (90837) provided from September 7, 2021, through September 21, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $30 copayment for each telehealth outpatient mental health or outpatient psychiatric individual therapy visit.      You have been asked to pay $90 ($30 copayment x 3 visits) for the outpatient telehealth psychiatric services provided on September 7, 2021, September 14, 2021, and September 21, 2021. 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 copayments for the psychotherapy services (90837) provided from September 7, 2021, through September 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the refraction services (92015) provided on September 13, 2021.  You asked the Plan to pay for the refraction services. You say that you do not believe that you should be charged for the services in question. The Plan denied your request. The Plan says that refraction services are not covered.  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. In this case, the services at issue are not covered by Medicare. However, the Evidence of Coverage we have received indicates that the Plan offers a supplemental benefit that does provide limited coverage for refraction services. There is no documentation that either states the enrollee was signed up for supplemental benefits or was not signed up for supplemental benefits. It is the burden of the Plan to adequately detail the enrollee's contract details.  Therefore, we decided that the Plan has to pay for the refraction services (92015) provided on September 13, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 11, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is: 

CPT 36246: 

Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family 

CPT 75716: 

Angiography, extremity, bilateral, radiological supervision and interpretation

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 36246 is inclusive to CPT 32776, due to an intervention performed. In this case, revascularization was performed. In terms of CPT 75716, all procedures necessary to perform a certain procedure, would be inclusive to that procedure, and not reported separately. In this case, CPT 32776 would require radiological supervision and interpretation to perform this procedure. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from March 28, 2021, through March 30, 2021

.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that due to the complexity of the aspiration pneumonia and possibly a urinary tract infection with respiratory distress and ongoing fever and emesis with liver enzymes positive, with concern for possible sepsis, there was an expectation that this enrollee would require hospital services that would likely cross 2 midnights based on the documentation provided leading up to admission.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 28, 2021, through March 30, 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 advanced care planning services coded 99497 provided on April 29, 2021.

You asked the Plan to pay for the advanced care planning services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of a discussion between the provider and the patient, along with family member(s), or surrogate(s), regarding eventual end-of-life decisions and preferences; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the advanced care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advanced care planning services coded 99497 provided on April 29, 2021.