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

 We decided that the Plan does not have to pay for the debridement services (11046) provided on June 23, 2021.  You asked the Plan to pay for the debridement services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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 11046 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 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 the debridement services. Our reviewer says that CPT code 11046 does not meet criteria for billing or reimbursement consideration. Our reviewer found the units for the services provided cannot be verified. Per CPT guidelines for debridement "Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound.  In multiple wounds, sum the surface area of those wounds that are the same depth, but do not combine sums from different depths".  In this case, measurements of depth debrided cannot be confirmed, to verify units billed.  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 debridement services have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services (11046) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for laboratory services provided on June 5, 2021.  You asked the Plan to waive the deductible for the laboratory services. You say that the services should be covered as you had a SNP active at the time. The Plan denied your request. The Plan says the deductible applied correctly, and you did not have an active SNP at the time of service.  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 a $203 deductible which applies to Outpatient hospital services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the laboratory services was received on June 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (97802) provided June 8, 2021.  You asked the Plan to pay for medical nutrition therapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease.  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.   Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (97802) provided June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provide don December 8, 2020, through December 15, 2020.  You asked the Plan to waive the copayment for inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $290 copay each day one through six for inpatient hospital care.   You have been asked to pay a $290 copay each day one through six for inpatient hospital care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan ($290 x 6 days = $1740). 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 inpatient hospital care provide don December 8, 2020, through December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy visits provided on April 27, 2021, to May 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the physical therapy visits. You say that your referring physician advised that the provider was in-network. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the physical therapy visits provided on April 27, 2021, to May 12, 2021 by an out-of-network (OON) provider.
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 March 12, 2020.  You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you had Medicaid at this time and should not owe anything. 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 20% coinsurance for Medicare Part B prescription drugs.     You received Medicare Part B drugs on March 12, 2020. The record shows that you had not had Medicaid at the time services were received. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $116.45 and 20% of that is $23.29.   You have been asked to pay the total coinsurance amount of $23.29 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 March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a walker provided on August 5, 2021  You asked the Plan to waive the coinsurance for the walker. You say that the services should be covered as you were told there would be no charges beforehand. The Plan denied your request. The Plan says the coinsurance applied correctly based on the item provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.         You have been asked to pay a 20% coinsurance for a walker (the allowed amount is $68.99 x 20% = $13.80). Walkers fall within the Durable medical equipment (DME) and related supplies 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 a walker provided on August 5, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted laboratory service (81479) provided on April 20, 2021.  You asked the Plan to pay for the unlisted laboratory service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.  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 unlisted laboratory service. Our reviewer says that the documentation does not support that the unlisted molecular path procedure was medically reasonable and 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 unlisted laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted laboratory service (81479) provided on April 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 15, 2020 to January 17, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of DRG 871, primary diagnosis A41.9, and secondary diagnoses R65.21 and J96.01.  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.    In this case, you billed the inpatient services provided with DRG 871, primary diagnosis A41.9 (sepsis, unspecified organism) and secondary diagnoses R65.21 (severe sepsis with septic shock), and J96.01 (acute respiratory failure with hypoxia). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 871, primary diagnosis A41.9, and secondary diagnoses R65.21 and J96.01. Our physician reviewer found the records support the admission for respiratory syncytial virus (RSV) pneumonia but are unclear regarding diagnoses of sepsis and respiratory failure. Although though sepsis and respiratory failure are documented in the records, there is no supporting documentation. The enrollee presented for chills, cough, and shortness of breath for five days. A chest x-ray showed left upper lobe pneumonia. The emergency room provider note states no respiratory distress and no accessory muscle use. The enrollee was admitted for asthma exacerbation and pneumonia. The records do not support the DRG 871, primary diagnosis A41.9, secondary diagnoses R65.21 and J96.01.   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 the inpatient hospital services rendered from January 15, 2020 to January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from July 3, 2020, through July 8, 2020, billed with the secondary diagnosis code of J90, defined as pleural effusion, not elsewhere classified.  You asked the Plan to pay for the inpatient hospital care as billed. You say that this care was billed with the appropriate secondary diagnosis code. The Plan denied your request. The Plan says the documentation does not support the secondary diagnosis code as billed.  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.    In this case, you billed the inpatient services provided with secondary diagnosis code, J90, defined as pleural effusion, not elsewhere classified. 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 inpatient hospital care as billed. Our reviewer says that the documentation does not support the inpatient hospital care as billed with the secondary diagnosis code of J90, defined as pleural effusion, not elsewhere classified. Our physician reviewer found that the review indicates that the patient presented with shortness of breath; in the emergency department, the x-ray report showed possible pleural effusion. The patient was admitted inpatient for chronic pulmonary exacerbation and treated with Levaquin, Solu Medrol and Duoneb. Documentation in the progress note noted that the chest x-ray was read as possibly right-sided pleural effusion. Further documentation in the consultation noted a fairly large pleural-based mass; the patient declined biopsy. Notation in the discharge diagnosis repeated the statement from the progress note: "CXR read as possibly right-sided pleural effusion, bilateral apical lung fibrotic changes, a 3.6 mm nodule in the right upper lobe. CT chest shows diffuse paraseptal and centrilobular emphysematous changes, multiple irregular." However, we could not find where the provider clarified the clinical significance of the condition nor showed that possible right-sided pleural effusion was confirmed, treated, managed, evaluated, or impacted patient care in any way in this encounter. The review has determined that the documentation did not continue to support the original billed secondary diagnosis code J90.   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 the inpatient hospital care provided from July 3, 2020, through July 8, 2020, billed with the secondary diagnosis code of J90, defined as pleural effusion, not elsewhere classified.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve porcelain fused to noble metal crowns (D2752) and core buildups (D2950) for teeth #4, #5, #14 and #15.  You asked the Plan to pre-approve crown services. You say that these teeth all present with visible recurrent decay and require crowns. Composite restorations will not provide a long-term prognosis and are insufficient for restoring these teeth. The Plan denied your request. The Plan says the requested dental services are not medically necessary. These teeth do not show significant breakdown or damage that can only be repaired with crowns. Each of these teeth only have one surface affected by recurrent decay and will have a good long-term prognosis with composite restorations.  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 covers crown services when the services are medically necessary and reasonable.   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 crown services. Our reviewer says that the criteria for coverage of buildups and crown restorations are not met for teeth #4, #5, #14 and #15. Our physician reviewer found that the documentation indicates that these teeth appear to need single surface (occlusal surface) restorations. There does not appear to be significant coronal breakdown due to caries or fracture. Therefore, the criteria for coverage of buildups and crown restorations are not met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crown services have not been met. Therefore, we decided that the Plan does not have to pre-approve porcelain fused to noble metal crowns (D2752) and core buildups (D2950) for teeth #4, #5, #14 and #15.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the abdomen (74018) rendered on September 3, 2021.  You asked the Plan to waive the copayment for an x-ray of the abdomen. You say that this x-ray was done based on a script from the primary care provider in an outpatient setting. You also say that per the Plan, imaging is 100% covered when done in an outpatient facility, so you do not understand why you are paying a $15 copayment for an x-ray. The Plan denied your request. The Plan says You were 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 $15 copayment for when x-rays are performed in an independent diagnostic testing facility (IDTF).   You have been asked to pay a $15 copayment for an x-ray of the abdomen. X-rays of the abdomen fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 an x-ray of the abdomen (74018) rendered on September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from August 30, 2021, to September 2, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you do not understand why the self-administered drugs were not covered. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare.  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-administered drugs provided from August 30, 2021, to September 2, 2021.   Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 services are not medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis. She has not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement (14040) provided on May 10, 2021.  You asked the Plan to pay for the adjacent tissue transfer or rearrangement. You say that you would like reconsideration because the services of the assistant at surgery were ordered by the in-network physician and medically necessary. The Plan denied your request. The Plan says assistants at surgery may not be paid for the service at issue.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 14040. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the adjacent tissue transfer or rearrangement have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement (14040) provided on May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided August 21, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you cannot afford the cost of the services. 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 $270 copayment per date of service regardless of the number of trips by ground ambulance.  You have been asked to pay a $270 copayment for the emergency ambulance services. The emergency ambulance services fall within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided August 21, 2021.