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

 We decided that the Plan does not have to pay for the diagnosis related group (DRG) based on the diagnoses billed.  You asked the Plan to pay for the DRG based on the diagnoses billed. You say that these services should be paid as billed. The Plan denied your request. The Plan says the diagnosis billed is not supported in the medical record.  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 diagnosis code M33.13- Other dermatomyositis without myopathy. 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 DRG based on the diagnoses billed. Our reviewer says that the diagnosis of other dermatomyositis without myopathy is not supported in the medical record. Our physician reviewer found the documentation indicates that dermatomyositis was documented by the provider in the history and physical and as a chronic disease would be valid for this admission as a chronic condition which requires ongoing monitoring during an encounter. The hospital referenced pulmonary fibrosis related to the diagnosis of dermatomyositis as requiring respiratory care and monitoring and included the use of incentive spirometry and orders for autopap post operatively as supportive evidence of ongoing respiratory assessment, and treatment for the condition. The medical record documentation was incomplete to support dermatomyositis met the definition of a secondary diagnosis during this episode of care. The documentation received for our review supported an admission for further evaluation and treatment of adenocarcinoma of the ascending colon for which a right hemicolectomy was performed. Although methotrexate (recorded as taken weekly) and folic acid (recorded as taken daily) are noted in the history and physical associated with the condition of dermatomyositis, and these medications were instructed to continue at discharge, the documentation was incomplete to reflect these medications were administered during this encounter or that a Pulmonary or Rheumatology consultation was required during the encounter.  The review has determined that the use of diagnosis code M33.13 was not supported by the records provided.   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 diagnosis related group (DRG) based on the diagnoses billed.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 63047-59  You asked the Plan to pay for procedure code 63047-59. You say that you have provided medical records to support payment of this code. The Plan denied your request. The Plan says the billed service is not supported by the medical records.  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.    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 procedure code 63047-59 Our reviewer says that the use of modifier -59 is not supported in the medical records. Our physician reviewer found you reported Current Procedural Terminology (CPT) 63047-59 : Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar with modifier 59 (Distinct Procedural Service).  The operative report describes procedures performed at the L1 - L2 level.  Documentation does not support modifier 59.   To report modifier 59 (Distinct Procedural Service), documentation would support distinct or independent services from other services performed on the same day.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 63047-59 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 63047-59
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-sharing for an injection of botulinum toxin (Botox) and chemodenervation procedure provided on June 25, 2021.  You asked the Plan to waive the cost-sharing for Botox injection and surgical service. You say that you are on a fixed income and thought the Plan would pay the full amount of these services. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 20% coinsurance for Botox and $45 copayment for surgical service. The allowed amount of the Botox injection is $1,211.80, resulting in a coinsurance amount of $242.36. Your total cost-sharing amount is therefore $287.36.  You have been asked to pay 20% coinsurance for Botox and $45 copayment for surgical service. Botox injection and surgical service fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 cost-sharing for an injection of botulinum toxin (Botox) and chemodenervation procedure provided on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on June 2, 2020, billed with codes 95870, 95938, 95939, and G0453.  You asked the Plan to pay for the IONM services as billed. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says the codes at issue are not supported by the records.  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 95870 is Needle electromyography (EMG); limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. The definition of code 95938 is Short-latency somatosensory evoked potential study (SSEP), stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs. The definition of code 95939 is Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.   The definition of G0453 is Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to 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 IONM services as billed. Our reviewer says that the billed codes are not supported in the record. Our reviewer found the procedure report does not document an EMG and therefore, code 95870 cannot be confirmed as performed. The report does not document SSEP from in upper and lower limbs, nor evoked potential study upper and lower limbs so 95938 and 95939 cannot be confirmed as performed.  The report does not document monitoring outside operating room so G0453 also cannot be confirmed as performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IONM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on June 2, 2020, billed with codes 95870, 95938, 95939, and G0453.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiographic images (D0210), and a comprehensive oral evaluation (D0180) provided by a participating provider on July 15, 2021.  You asked the Plan to pay for radiographic images and a comprehensive oral evaluation. You say that this should be covered 100%. The Plan denied your request. The Plan says the dental services that were provided have already been exhausted.  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 radiographic images once every five years and a comprehensive oral evaluation once every three years.  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of radiographic images and a comprehensive oral evaluation have already been exhausted.  Evidence was provided that shows D0180 and D0210 were exhausted on July 20, 2020. Therefore, we decided that the Plan does not have to pay for radiographic images (D0210), and a comprehensive oral evaluation (D0180) provided by an in-network provider on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 45990 billed for date of service April 29, 2021.  You asked the Plan to pay for procedure code 45990. You say that you have provided medical records to support this billing. The Plan denied your request. The Plan says the billed code is not supported by the medical records.  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 45990 is Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural).  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 procedure code 45990. Our reviewer says that this procedure code is not supported by the medical records.  Our reviewer found the operative report does not include documentation of a surgical anorectal exam.  This procedure is not documented, and therefore it cannot be confirmed that this procedure has been performed based on the records provided.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 45990 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 45990 billed for date of service April 29, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve the laminectomy, facetectomy and foraminotomy (63047).  You asked the Plan to pre-approve the laminectomy, facetectomy and foraminotomy. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says that this code cannot be billed separately from another part of the procedure.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   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 laminectomy, facetectomy and foraminotomy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the determination is limited to the provision of the services. The billing of a separately payable codes can be determined if the services are billed as such.  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 laminectomy, facetectomy and foraminotomy have been met. Therefore, we decided that the Plan has to pre-approve the laminectomy, facetectomy and foraminotomy (63047).   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 copayment for  a specialist office visit (99213) rendered on March 18, 2021.  You asked the Plan to waive the copayment for a specialist office visit. You say that the doctor cancelled the follow up visit on February 25, 2021, and rescheduled it for March 18, 2021. You also say that you specifically inquired at your check-in if there was a copayment due and the person at the desk checked your chart and said there was no copayment. You also say that you received a bill 6 months after your office visit. 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 $40 copayment for each specialist visit for Medicare-covered services.     You have been asked to pay a $40 copayment for a specialist office visit. The record shows that even if the specialist office visit was not originally rescheduled, nothing in the Evidence of Coverage (EOC) says the copayment would be waived. 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 (99213) rendered on March 18, 2021.   Your complaint about the provider cancelling your appointment and potentially denying that you were told no copayment was due is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wig received on March 12, 2021.  You asked the Plan to pay for the wig. You say that you feel the plan should pay for some part of this item. The Plan denied your request. The Plan says the item received is not a covered benefit.  Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.  In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig received on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services provided on January 25, 2021.  You asked the Plan to pay for the dental services. You say that the dentist couldn't fix the teeth and it was impossible to eat. You say that a root canal was the solution, and the services should be covered. The Plan denied your request. The Plan says services obtained from vendors outside the 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lower partial denture provided on December 28, 2020.  You asked the Plan to pay for the lower partial denture. The Plan denied your request. The Plan says the annual limit allowed by your dental plan has been paid.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $1,000 every year for covered dental services. The Plan paid $1,000 toward dental services prior to receiving the partial denture, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the lower partial denture provided on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 31225 billed for date of service November 18, 2020.  You asked the Plan to pay for procedure code 31225. You say that you have provided medical records to support payment. The Plan denied your request. The Plan says the billed services are not supported by the medical records.  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 31225 is maxillectomy; without orbital exenteration.  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 procedure code 31225. Our reviewer says that procedure code 31225 is not supported by the medical records provided. Our reviewer found the operative report describes an endoscopic right medial maxillectomy.   Procedure code 31225 should be reported for an open procedure. There is a more appropriate "unlisted" code to report for this service.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 31225 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 31225 billed for date of service November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient care provided from July 27, 2020, through July 30, 2020 billed with secondary diagnosis code J96.21.  You asked the Plan to pay for the inpatient care as billed. You say that this claim was correctly coded as the enrollee clearly had symptoms of acute and chronic respiratory failure. The Plan denied your request. The Plan says this diagnosis is not supported.  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 J96.21, defined as acute and chronic 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 the inpatient care as billed. Our reviewer says that the reported secondary diagnosis code is not supported. Our physician reviewer found while the enrollee's presentation warranted consideration for acute and chronic respiratory failure with hypoxia as a diagnosis there was no documentation of a respiratory rate over 30, use of accessory muscles, or other issues related to hypoxia. Also, there was no documentation of treatment consistent with acute respiratory failure, such as administration of oxygen of at least 5 liters per minute, use of bilevel positive airway pressure, or mechanical ventilation. The review has determined that the documentation did not support the reporting of J96.21 (Acute and chronic respiratory failure with hypoxia) as a secondary diagnosis for this hospital stay.   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 care provided from July 27, 2020, through July 30, 2020 billed with secondary diagnosis code J96.21.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management services coded 99238 provided on August 11, 2020.  You asked the Plan to pay for the hospital discharge day management 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 supported by the documentation.  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 99238 is hospital discharge day management; 30 minutes or less.   We find that CPT code 99238 is not supported in the medical record. Specifically, no medical records were provided for this date of service to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99238 provided on August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital evaluation and management (E&M) visits provided from August 12, 2021, to August 15, 2021.  You asked the Plan to pay for hospital E&M services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because diagnosis codes M84.48XA and S32.10XA should not be reported together.  The Plan must follow Medicare rules. Medicare rules say that S32 diagnosis codes should never be used at the same time as diagnosis code M84.48XA.     We looked at the file and Medicare rules. This claim was billed with diagnosis codes that should not be reported together. Based on this information, we decided that Medicare rules for coverage of hospital E&M services have not been met. Therefore, we decided that the Plan does not have to pay for hospital evaluation and management (E&M) visits provided from August 12, 2021, to August 15, 2021.