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

We decided that the Plan does not have to pay for moderate sedation service (99153) provided on February 4,
2021.
You asked the Plan to pay for moderate sedation. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is
not separately paid for a hospital outpatient.
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a
practice expense (PE) only code and is not paid in the facility setting.
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does
not have to pay for moderate sedation service (99153) provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-evaluation (D0170) provided on September 14, 2021.
You asked the Plan to pay for the dental service. You say that you had a serious infection and severe pain. You say that this visit was essential to make a correct diagnosis. You also say that you feel this should be covered. The Plan denied your request. The Plan says re-evaluation is not listed as a covered service.
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 re-evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-evaluation (D0170) provided on September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on June 4, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport does not meet the Plan's coverage criteria.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found that the enrollee is an 81-year-old male who was transported via ambulance services for a non-emergent, scheduled pick-up from the hospital to his home after a hospital stay to treat a urinary tract infection and sepsis. The enrollee's vitals were stable. He was transported via stretcher without incident or need for any treatment. His vitals remained stable. The documentation does not support that other means of transport (such as stretcher van) were contraindicated for this enrollee on June 4, 2021.

The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on June 4, 2021. The documentation does not support that the ambulance transport on June 4, 2021 was medically reasonable and necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a total hip arthroplasty (27130) provided on May 27, 2021, by an out-of-network provider.
You asked the Plan to pay for a total hip arthroplasty. 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 for out-of-network care have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 a total hip arthroplasty (27130) provided on May 27, 2021, by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and excisions (11422, 11421, 11404, 11403 and 11402) provided on August 19, 2021.
You asked the Plan to pay for the office visit and excisions. You say that you would like reconsideration because the excision services were medically necessary. The Plan denied your request. The Plan says these services fall within the global surgery period of the services rendered on August 9, 2021.
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit and excisions have not been met. Specifically, the record indicates that the member had excision services rendered on August 9, 2021. These services have a global surgery period of 10 days. The services at issue in this appeal fall within the 10-day global surgery period. Of note, the documentation submitted does not include sufficient clinical information to determine if the services rendered on August 19, 2021 were unrelated to the services rendered on August 9, 2021. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and excisions (11422, 11421, 11404, 11403 and 11402) provided on August 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 11, 2021, to April 14, 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 DRG was updated.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee is an 86 year old female who was admitted to the hospital. Respiratory failure with hypoxia was listed as a diagnosis. The enrollee was not noted to be in any respiratory distress and she had an acute gall bladder attack but no primary respiratory failure noted. Therefore, the records do not sufficient support the DRG and diagnosis of respiratory failure with hypoxia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from April 11, 2021, to April 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on July 29, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 76705 was billed with code 93976. 

We looked at the file and the rules. We find that CPT code 76705 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the knee (73562) provided on June 9, 2021, by an out-of-network provider.
You asked the Plan to pay for an X-ray of the knee. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 an X-ray of the knee (73562) provided on June 9, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient office visit (99203) provided on July 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient office visit. You say that the patient came to your outpatient office at the facility; therefore, these services are rendered in an outpatient office setting. You also say you were referred by the nursing facility to see the patient. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and a valid authorization was not obtained prior to the services being rendered. The Plan also says that in-network providers were available. The Plan also says that it was determined that the services 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 an outpatient office visit (99203) provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 19, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have power options of tilt, and power elevating leg rests on the approved wheelchair but you do not need to control the power options through a joystick. Your upper extremity function with independence in feeding and grooming support that you can control any power options through their own switches. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on August 17, 2021.
You asked the Plan to pay for the ultrasound. 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 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 76705
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the ultrasound coded 76705 provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 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 provided did not bill as required by Medicare coding regulations.
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 72170 is a column II code to column I code 73521. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services provided to the enrollee on May 18, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device (E0601) and tubing for CPAP device (A4604) provided on July 7, 2021.
You asked the Plan to pay for a CPAP device and tubing. You say that your previous CPAP device was recalled requiring the purchase of a replacement. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the items at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a CPAP device (E0601) and tubing for CPAP device (A4604) provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the lab testing provided on September 2, 2021.

You asked the Plan to waive the charges for the hospital lab testing. You say that you have been getting these tests done for almost a year and have never had to pay for this. You feel that the $40 copayment is incorrect. The Plan denied your request. The Plan says this was correctly assessed the $40 copayment for lab testing provided by a hospital.

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 lab services provided in the outpatient hospital setting for lab services provided in the outpatient hospital setting. 

You have been asked to pay a $40 copayment for lab services provided in the outpatient hospital setting for the hospital lab testing. The hospital lab testing falls within the lab services provided in the outpatient hospital setting 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 charges for the lab testing provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 10, 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 documentation provided on appeal do not support that each procedure was performed at separate times.
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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 27,
2021.
You asked the Plan to pay for the x-ray 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 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 71045
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 27, 2021.