Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apexification/recalcification (D3352), guided tissue
regeneration (D4266), and bone replacement graft for ridge preservation (D7953) or pay more for the surgical
extraction (D7210) provided on June 25, 2021, and June 29, 2021.
You asked the Plan to pay for the apexification/recalcification, guided tissue regeneration, and bone
replacement graft, and to pay more for the surgical extraction. You say that you feel you should be reimbursed
something for these services. The Plan denied your request. The Plan says the apexification/recalcification,
guided tissue regeneration, and bone replacement graft are not covered. The Plan also says that you are
responsible for the coinsurance amount applied to the extraction, and you were provided with no
misinformation when you contacted the Plan on January 15, 2021.
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 apexification/recalcification, guided tissue regeneration, and bone replacement graft are not among those covered under this benefit. The contract clearly states that you are responsible for a 50% coinsurance for surgical extractions (D7210). Therefore, we decided that the Plan does not have to pay for the apexification/recalcification (D3352), guided tissue regeneration (D4266), and bone replacement graft for ridge preservation (D7953) or pay more for the surgical extraction (D7210) provided on June 25, 2021, and June 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided from May 3, 2021, through May 17, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says since the enrollee was not transported to the hospital, there is no payable service for these
ambulance response, no transport events.
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 from May 3, 2021, through May 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 response and
treatment, no transport (A0998) provided from May 3, 2021, through May 17, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider on July 12, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 services at issue in this appeal.

The Plan did not pre-approve the services 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 the medical services rendered by the out-of-network (OON) provider on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99202) and electrical stimulation (G0283) provided from June 15, 2021, through July 28, 2021.  You asked the Plan to pay for the office visit and electrical stimulation. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are never covered when performed by a chiropractor.  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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and electrical stimulation (G0283) provided from June 15, 2021, through July 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 

 You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 5, 2022, forward and could have been treated in a lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors while being cooperative and compliant.  

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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a dental crown (D2740), core build up (D2950), composite services (D2330, D2391) provided from August 2, 2021, through August 9, 2021.  

You asked the Plan to pay for the dental services. You say that you would like these claims reprocessed based on the work the dentist put in. The Plan denied your request. The Plan says the claims have processed correctly.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's dental benefit includes a 50$ deductible for dental services, a $100 annual benefit limit per tooth for dental crowns and a 50% coinsurance for composite fillings with an in-network provider.    

We looked at the file, and Medicare rules. In this case, the file indicates that the Plan has correctly charged you the $50 dollar deductible for dental services rendered. In addition, the Plan has correctly applied the $100 annual benefit for dental crown services per tooth. Therefore, the dental crown and core build up have paid correctly as the Plan has paid the benefit limit and left you with the remaining amount. Finally, the composite services have processed correctly with a 50% coinsurance left for you to pay. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for a dental crown (D2740), core build up (D2950), composite services (D2330, D2391) provided from August 2, 2021, through August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225) provided on June 28, 2021.  You asked the Plan to pay for the dental item. You say that you were led to believe that the dentist was in network. You say that the office was taking your insurance card all year without saying anything. You say that you would not have had this work done if you had known it would not be covered. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225) provided on June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that this service was rendered due to medical necessity and the care was provided as an urgent request to avoid wound complications. The Plan denied your request. The Plan says no authorization was obtained, it was not an emergency service, and there are network providers available for the delivery of this service.

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 subsequent nursing facility care (99308) provided on July 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 the moderate sedation services (99152) provided on June 18, 2021.

You asked the Plan to pay for code 99152. You say that the medical records support the billing of code 99152. The Plan denied your request. The Plan says the medical records do not support the billing of code 99152.

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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

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 code 99152. Our reviewer says that the medical records do not support the billing of code 99152. Our reviewer found the enrollee underwent placement of a chest port with fluoroscopic and ultrasound guidance. It is documented that the enrollee was consciously sedated with Versed and Fentanyl. The interventional radiologist documents, "The patient was monitored by me for 37 minutes." The documentation does not support requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. Code 99152 is not supported.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided on June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Arthrodesis services (27280) provided on April 14, 2021.

You asked the Plan to pay for code 27280. You say that the medical records support the billing of code 27280 provided on April 14, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of code 27280 provided on April 14, 2021.

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 27280 is Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed. 

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 code 27280. Our reviewer says that the medical records do not support the billing of code 27280 provided on April 14, 2021. Our reviewer found the Operative Note does not include documentation of an open arthrodesis of the sacroiliac joint, including obtaining bone graft, including instrumentation, when performed. Code 27280 is not supported. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 27280 have not been met. Therefore, we decided that the Plan does not have to pay for the Arthrodesis services (27280) provided on April 14, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for tissue transfer procedures provided on May 20, 2021.

You asked the Plan to pay for tissue transfer procedures. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the records do not support the use of codes 14301 and 14302.

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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 

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 tissue transfer procedures. Our reviewer says that these codes meet criteria for payment. Our reviewer found on May 20, 2021 the enrollee underwent a scalp adjacent tissue rearrangement, 10 x 11 cm. It is documented, "The scalp flap was inspected. There was some soft tissue contracture which was expected since the bone flap was missing for a while. A back cut was made in order to advance the flap into the defect. Total area rearranged was 10x 11 cm for a total of 110 square centimeters. Once the back cut was made, the hemostasis was again controlled with cautery, sergiflo. The flap was inset with 2-0 PDS and 3-0 chromic sutures. Two blake drains were placed through separate stab incisions in the skin and secured with 3-0 nylon sutures. Dressings were applied." The documentation in the operative report supports the use of CPT/HCPCS Codes 14301 and 14302. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfer procedures have been met. Therefore, we decided that the Plan has to pay for tissue transfer procedures provided on May 20, 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 waive the coinsurance for Medicare Part B drugs provided on July 27, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that you would owe 10% of $163 and now you are being charged 30 times that. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 10% coinsurance for Medicare Part B prescription drugs.

You received Medicare Part B drugs on July 27, 2021. The total allowed amount is $5,178.52 and 10% of that is $517.84. 

You have been asked to pay the total coinsurance amount of $517.84 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on July 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a physical therapy (PT) evaluation (97162) provided on May 3, 2021.

You asked the Plan to waive the copayment for a PT evaluation. You say that prior to your surgery, you called the Plan, and you were told that you would have a copayment of $225 because your surgery was an outpatient surgery. You also say you paid the copayment for your surgery and you now disagree with the additional copayment charge. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 Medicare covered physical therapy visit. 

You have been asked to pay a $30 copayment for a PT evaluation. The records show you had an outpatient surgery, and the correct copayment was applied. The records also show that you received a PT evaluation. The EOC confirms $30 is the required copayment for this service. A PT evaluation falls within the outpatient rehabilitation services 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 physical therapy (PT) evaluation (97162) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a lipid panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 25, 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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 your medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the you require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 the abdominal x-ray services provided on September 26, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. 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 74018 was billed with 74019. We find that CPT code 74018 may be eligible for payment when billed with this code pair. The claim information provided does not show that code 74018 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 x-ray services provided on September 26, 2021.