Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided from November 7, 2020 to November 8, 2020.
You asked the Plan to pay for code 99291. 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 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress notes for November 7, 2020 and November 8, 2020 do not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided from November 7, 2020 to November 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. 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 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 to the enrollee on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the billed codes 95955, 95937, and 95908 provided March
15, 2021.
You asked the Plan to pay for the billed codes 95955, 95937, and 95908. You say that you would like these
claims reprocessed for medical necessity. The Plan denied your request. The Plan says the documentation does
not support that the codes were performed 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, the CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. Finally, the CPT Code Manual definition of code 95908 is Nerve conduction studies; 3-4 studies. 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 billed codes 95955, 95937, and 95908. Our reviewer says that the documentation does not support the codes as billed were performed. Our reviewer found that for CPT 95955, the submitted technical report documents "real time" monitoring. There is a more appropriate HCPCS code to report for this service. The additional EEG would be included with the correct monitoring code. Next, for CPT 95937 the submitted technical report does not document neuromuscular junction testing was performed, and therefore, cannot be confirmed as performed. Provider documents "95937: Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, an 1 method ** Supporting documentation can be found in the attached TECHNICAL REPORT ** Additional supporting documentation can be found on the attached INTRAOPERATIVE NEUROPHYSIOLOGY under Conditions of the Recording and Description of the Recording". However, this documentation was not found to support reporting this code. Finally for CPT 95908 - the technical report documents "pedicle screw were stimulated" this is an incorrect code to report for nerve conduction studies as a electrodes are used to assess amplitude, latency, and configuration. This is not documented in the technical report, and therefore cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the billed codes 95955, 95937, and 95908 have not been met. Therefore, we decided that the Plan does not have to pay for the billed codes 95955, 95937, and 95908 provided March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the one crown (D2740) or pay more for the additional crown
(D2740) provided on March 10, 2021.
You asked the Plan to pay for the crowns. You say that you were told that this plan would cover any dental
services up to $2,000 per year. The Plan denied your request. The Plan says you have received the maximum
amount of your Plan's dental benefit. The Plan also says that you are responsible for the remaining $1,500 of
the billed amount for these services.
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 Plan offers an annual maximum
benefit of $1,000 for dental services. The record shows that you met the annual maximum benefit when this
claim for the March 10, 2021, date of service was reprocessed for payment and your annual maximum benefit
has been exhausted. The record shows that you were not misinformed by the sales broker that you had a $2,000
dental benefit. Therefore, we decided that the Plan does not have to pay for the one crown (D2740) or pay more
for the additional crown (D2740) provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator provided on February 8, 2021.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received durable medical equipment on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an automatic external defibrillator on February 8, 2021. You have been asked to pay a 20% coinsurance for the automatic external defibrillator, totaling $586.29. The automatic external defibrillator falls within the Durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator provided on February 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services (93922, 93886, 93890, 93892, 92537, 92540 and 92546) provided on February 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the lab testing. You say that there was a miscommunication and prior authorization was not requested before services were rendered. You performed this care in good faith under the assumption that staff had obtained authorization. The Plan denied your request. The Plan says out-of-network services are only covered in limited circumstances. The services in question required prior authorization, which was not obtained. In addition, the Plan reached out to the enrollee who confirmed they did not have services from you. Upon outreach to your office, the Plan was advised that the enrollee is not an established patient and no medical records could be provided.
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. In addition, the rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 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. In addition, no documentation was provided to support that these services were rendered or meet Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the lab testing services (93922, 93886, 93890, 93892, 92537, 92540 and 92546) provided on February 19, 2021 by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on February 14, 2020.
You asked the Plan to pay for physical therapy services. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, PT services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on February 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on May
26, 2021, by an OON provider.
You asked the Plan to pay for nursing facility care. You say that you have attached the medical records for the
date of service. You are requesting review of the documents and processing of the claim towards payment. The
Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted
providers require prior authorization before services being rendered.
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 subsequent nursing facility care (99309) provided
on May 26, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your condition has improved and you are no longer a threat to yourself or others.
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 pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you are not showing any dangerousness to self or others, auditory or visual hallucinations and are without aggressive behaviors while not showing any acute threats of safety. You were cooperative and compliant with treatment described as being calm, polite and compliant. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Drugs
Decision: Unfavorable

decided that the Plan does not have to pre-approve Invega Sustenna.
You asked the Plan to pre-approve Invega Sustenna. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invega Sustenna.
Benefits for Invega Sustenna may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the posterior tibial nerve stimulation treatment provided on January 12, 2021.
You asked the Plan to waive the deductible for the posterior tibial nerve stimulation treatment. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received posterior tibial nerve stimulation treatment on the date of service at issue in this appeal. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $100 deductible which applies to Outpatient surgery.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $100 deductible which applies to Outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the posterior tibial nerve stimulation treatment was received on January 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the posterior tibial nerve stimulation treatment provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral x-ray (D0210) and panoramic x-ray (D0330) provided on June 7, 2021.
You asked the Plan to pay for the comprehensive oral evaluation (D0150), intraoral x-ray (D0210) and panoramic x-ray (D0330). You say that you canceled this, and the account no longer exists. The Plan denied your request. The Plan says the services exceed the maximum amount allowed per period.
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, you also have a maximum benefit of one comprehensive oral evaluation, intraoral x-ray and panoramic x-ray every three plan years. The Plan paid for the comprehensive oral evaluation and intraoral x-ray provided on June 29, 2020 and the panoramic x-ray provided on April 21, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral x-ray (D0210) and panoramic x-ray (D0330) provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the appealed codes are authorized except for E2311, E2313, and E2377.

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 pre-approve the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that you meet Medicare criteria for coverage of these accessories. The provided records document 4/5 left upper extremity and range of motion within functional limits, thus indicating adequate strength and function to control the power options with their own switches. 

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 3, 2021.
You asked the Plan to pay for these services. You say that the Plan should cover these services. 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 June 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease represented by code 99072 provided from January 28, 2021 to April 13, 2021.
You asked the Plan to pay for code 99072. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease represented by code 99072 provided from January 28, 2021 to April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 26, 2021.
You asked the Plan to pay for code 99291. 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 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for March 26, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 26, 2021.