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

 We decided that the Plan does not have to pay for catheter placement procedures (36222-50-58, 36225-59-LT) provided on May 3, 2021. You asked the Plan to pay for catheter placement procedures. You say that this was billed with modifiers to surpass the code edits. The Plan denied your request. The Plan says these codes are not separately payable.  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 36222 is a column II code to column I code 36223, and code 36225 is a column II code to 36226. Although these codes were submitted with modifiers to indicate that they were separate services, the records do indicate that they were performed in a separate encounter or for a different indication than the column I codes. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for catheter placement procedures (36222-50-58, 36225-59-LT) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Hereditary Cardio Screening test provided on September 14, 2020.  

You asked the Plan to pay for the Hereditary Cardio Screening test. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare only covers the basic lipid panel in symptomatic patients.  

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 Hereditary Cardio Screening test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided documentation this test was ordered for screening purposes. Also, there is insufficient evidence that shows this testing leads to significantly improved outcomes to justify its regular use in patients.  

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 Hereditary Cardio Screening test have not been met. Therefore, we decided that the Plan does not have to pay for the Hereditary Cardio Screening test provided on September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation that you will require a greater than 2 midnight stay.

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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You have right knee arthritis. A request was made for inpatient admission for a total knee arthroplasty procedure. You have a history of glaucoma, hyperlipidemia, hypertension, however, you were provided medical clearance for the procedure. Based on the provided documentation, there was no expectation that you would require hospital services that would likely cross 2 midnights for this elective typically ambulatory procedure. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient 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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy for the enrollee.  You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says as the enrollee improves, less skilled care is needed.  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 the therapy.  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 the enrollee has previously been treated with outpatient therapies, and should be independent at this point with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for the treatment of the enrollee's medical condition. Therefore, the request is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided October 17, 2019.  You asked the Plan to pay for the non-emergency ambulance services. You say that the prior authorization was the hospital's responsibility, not yours. The Plan denied your request. The Plan says this service does not meet criteria for coverage.  Medicare pays for ambulance services only when they are medically reasonable and necessary. Your contract with the Plan clearly says that prior authorization is required for non-emergency Medicare-covered ambulance transport.  We looked at the file and Medicare rules. In this case prior authorization was not obtained prior to the non-emergency ambulance transport. Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested for community use.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 scooter. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found the documentation does not indicate if your mobility deficit significantly impairs participation in MRADLs in the home, such as toileting, feeding, grooming and bathing in customary locations within the home. You are able to use a four-wheeled walker, and you manage your own showers, dressing, and toileting.  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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214-25) provided on July 6, 2021.  You asked the Plan to pay for office visit. You say that this code is payable for the service provided. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 98929 has a global period value of 000 meaning that an evaluation and management service on the same date is not separately payable, so this does not meet industry coding standards.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. The definition of code modifier -25 is significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.  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 office visit. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the documentation describes an established patient returned to the office for osteopathic manipulative treatment related to pain. The documentation includes the reason the enrollee returned to the office and the treatment given. The documentation does not support a separately identifiable service performed on the same day as treatment. As osteopathic manipulative treatment has a global period, the evaluation and management service would not be separately reimbursable.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214-25) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory services rendered on September 3, 2021.  You asked the Plan to waive the copayment for these services. You say that you should not have 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 $10 copayment for Medicare-covered laboratory tests that are not FIT tests.   Review of the file shows that you received laboratory services on September 3, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the Medicare-covered laboratory tests that are not FIT tests 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 laboratory services rendered on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-adminstered drugs received on August 9, 2021.  You asked the Plan to pay for the self-adminstered drugs. You say that you cannot afford this ridiculous charge for these pills. The Plan denied your request. The Plan says the drugs received are not a covered benefit.     The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pay for the self-adminstered drugs received on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (64492) provided on July 2, 2021.  You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.  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 injections (64492) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on August 13, 2021.  You asked the Plan to pay for these services. You say that the provider told you that the services were covered 100 percent. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted a claim for procedure code 99203 (office visit). The Plan cannot be held responsible for possible coverage misinformation given by a provider. Therefore, we decided that the Plan does not have to pay for the office visit rendered on August 13, 2021.
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 July 28, 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 July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on February 18, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that your appointment was in the doctor's office and not an outpatient facility. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist office visits.   You have been asked to pay a $40 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the outpatient surgical procedure coded as 99204, 24077, 14301, 14302, 27329, 13121, 13122 provided August 5, 2021.  You asked the Plan to pay for the outpatient surgical procedure. You say that  The Plan denied your request. The Plan says that   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 says that you cannot be asked to pay more than $65 copayment for surgery services in an out of network PCP or Specialist's office visit. It is the Plan's obligation to ensure that the enrollee only pays for their contractual cost-share obligation. In this case the total amount for the services was $4,512.25, which you had paid in full. The Plan paid $1,520.32 which was sent to the provider and the provider forwarded to you. The Plan must reimburse you the amount of $2,926.93 paid in excess of your copayment. Therefore, we decided that the Plan has to reimburse you for the outpatient surgical procedure coded as 99204, 24077, 14301, 14302, 27329, 13121, 13122 provided August 5, 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 direct laryngoscopy (31525), tracheostoma revision (31613), and an esophagoscopy (43200) provided on July 15, 2021.  You asked the Plan to pay for laryngoscopy 31525, tracheostoma revision 31613, and esophagoscopy 43200. You say that you are appealing with notes to support all codes billed. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are inclusive to code 31360 and are not supported for separate payment.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records do not show that these services were part of a separate, distinct procedure from the laryngectomy (31360) to which they are inclusive. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for direct laryngoscopy (31525), tracheostoma revision (31613), and an esophagoscopy (43200) provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for a computerized corneal topography, unilateral or bilateral, with interpretation and report (92025) provided on June 21, 2021.  

You asked the Plan to pay for the computerized corneal topography, unilateral or bilateral, with interpretation and report. You say that a test ordered by an in-network doctor, whether an ophthalmologist or other specialist, is normally covered by the insurance policy. The Plan denied your request. The Plan says that this service is not a covered benefit.  

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the Plan unless notice is provided that the services will not be covered. The Plan follows these rules.

  You were referred for the computerized corneal topography, unilateral or bilateral, with interpretation and report by a contract provider. The file does not show that the Plan provided notice that the computerized corneal topography, unilateral or bilateral, with interpretation and report would not be covered prior to the service being rendered. Under Medicare rules, this means the computerized corneal topography, unilateral or bilateral, with interpretation and report is considered approved by the Plan. Therefore, we decided that the Plan has to pay for a computerized corneal topography, unilateral or bilateral, with interpretation and report (92025) provided on June 21, 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room services rendered on February 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 claim was not billed correctly.  The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.  We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary diagnosis code. Therefore, we decided that the Plan does not have to pay for the emergency room services rendered on February 13, 2021.