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

We decided that the Plan does not have to waive the coinsurance for the design and construction of radiation therapy provided on April 19, 2021.

You asked the Plan to waive the coinsurance for the design and construction of radiation therapy. You say that you did not receive any services on April 19, 2021 and should not be responsible for the charges. 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 therapeutic radiology services. The total allowed amount is $5,296.56 an 20% of that is $1,059.30.

The medical records show that you received the design and construction of radiation therapy on April 19, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $4,538.52 and 20% of that is $907.70. 

You have been asked to pay the total coinsurance amount of $907.70 for the design and construction of radiation therapy. The design and construction of radiation therapy falls 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 coinsurance for the design and construction of radiation therapy provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this request is
medically necessary. The Plan denied your request. The Plan says coverage cannot be provided for equipment
used in an institution classified as a SNF.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that a group 3 power wheelchair and accessories is being requested for use in a SNF or hospital.
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 29, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON drug testing. You say that the enrollee should not be penalized due to an authorization issue as this was medically necessary testing. The Plan denied your request. The Plan says this testing was provided out of network with no referral from a network provider nor 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 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 drug testing services provided on September 29, 2020 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded 76705 provided on May 26,
2021.

You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are 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
for the ultrasound services have a bundled relationship with code 93976 and cannot be paid as billed. This code
cannot be paid as a separate line item. 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 services coded 76705 provided
on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by an out-of-network (OON) provider on June 19, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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. 

You are not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99214) rendered by an out-of-network (OON) provider on June 19,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional time spent on critical care services coded
99292 and the insertion of non-tunneled centrally inserted central venous catheter coded 36556 provided from
July 1, 2020, to July 10, 2020.

You asked the Plan to pay for the additional time spent on critical care services and the insertion of nontunneled
centrally inserted central venous catheter. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as 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.

We find that CPT codes 99292 and 36556 are not supported in the medical record. Specifically, code 99292
should be billed with modifier 24 for these dates of service to indicate that the critical care was unrelated to the
specific anatomic injury or general surgical procedure performed. This code did not include modifier 24. The
documentation shows that code 36556 is not payable as billed as it was within the global period of procedure
code 15120 performed by the same provider. This means this code is not separately payable. Based on this
information, we decided that Medicare rules for coverage of the additional time spent on critical care services
and the insertion of non-tunneled centrally inserted central venous catheter have not been met. Therefore, we
decided that the Plan does not have to pay for the additional time spent on critical care services coded 99292
and the insertion of non-tunneled centrally inserted central venous catheter coded 36556 provided from July 1,
2020, to July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on February 19, 2021.

You asked the Plan to pay for critical care, evaluation and management of the critically ill or critically injured
patient; first 30-74 minutes (99291). You say that the Plan should pay this claim. The Plan denied your request.

The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was
performed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
critical care time spent to corroborate the services. Based on this information, we decided that Medicare rules
for coverage of critical care, evaluation and management of the critically ill or critically injured patient; first
30-74 minutes (99291) have not been met. Therefore, we decided that the Plan does not have to pay for critical
care services provided on February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81400, 81401, 81401, 81479 and 81479 provided on April 27, 2021.

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 are not payable as 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. 

We find that CPT code 81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81400, 81401, 81401, 81479 and 81479 is not supported in the medical record. Specifically, the services billed represent part of an expanded pharmacogenomic panel. If a laboratory procedure produces multiple reportable test results, only a single code shall be reported for the procedure. If there is no code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service.

Review of the file shows that the services rendered should be billed with code 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81400, 81401, 81401, 81479 and 81479 provided on April 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixteen (16) additional PT and OT visits.

You asked the Plan to pre-approve sixteen (16) additional PT and OT visits. You say that additional therapy is medically necessary. The Plan denied your request. The Plan says additional therapy is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve sixteen (16) additional PT and OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested physical and occupational therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee was authorized for four (4) additional sessions each of PT and OT and can transition to a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sixteen (16) additional PT and OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve sixteen (16) additional PT and OT visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.

You asked the Plan to pre-approve 12 additional physical therapy visits. You say that 12 additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says 12 additional physical therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was already approved. The enrollee has been already authorized additional therapy and can transition to a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation (E0730).
You asked the Plan to pay for the TENS device. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says TENS units and garments and supplies for chronic back/neck pain/radiculopathy are not a Medicare covered benefit.
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 TENS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the requested transcutaneous Electric Nerve Stimulation (TENS) units and garments and supplies for chronic back/neck pain/radiculopathy are not a Medicare covered benefit. The review has determined that the medical records provided did not meet the requirements listed in the NCD for Medicare coverage. 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 TENS device have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation (E0730).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires, per pair (A4557) provided May 4, 2021.
You asked the Plan to pay for the lead wires. You say that this claim denied for invalid modifier and that your
services are considered included in the inpatient rate allowed for the same day, but this is incorrect. The Plan
denied your request. The Plan says unbundled services. This service is bundled into the payment for other
services not specified and no separate payment is made per Medicare.
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 the
lead wires has a bundled relationship with another service and cannot be paid as billed. This code cannot be
paid as a separate line item. 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 lead wires, per pair (A4557) provided May 4,
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) skilled nursing visits (CPT code G0299 X 6), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 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 services. Our physician reviewer found the records do not show that home health skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee had had education on hydration, nutrition. There are no safety concerns. There are no complex wounds or new enteral feedings. The skills of a professional nurse are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) skilled nursing visits (CPT code G0299 X 6), for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for COVID-19 laboratory testing provided on January 7, 2021, and January
26, 2021.
You asked the Plan to pay for lab tests. You say that these tests were done to manage the enrollee's exposure to
care workers and other residents who may have come in contact with COVID-19. The Plan denied your
request. The Plan says that the denial of payment for this testing is correct, because the provider did not submit
the lab test results upon request.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan says that they did not receive the lab results from this testing after
making requests to the provider on July 28, 2021, August 4, 2021, and August 9, 2021. However, the Plan has
not provided documented attempts to obtain the medical records to support that they attempted to obtain
records on these dates or any other dates. Without this information, the Plan has not shown that their decision
to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that
the Plan has to pay for COVID-19 laboratory testing provided on January 7, 2021, and January 26, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210,
81270, 81275, 81293, 81299, 81318) provided on April 27, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also state that code 81479 is used to
report Guardant360 testing.
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81270, 81275, 81293, 81299, and 81318 are not
supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which
should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for
Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81270, 81275, 81293, 81299, 81318) provided on
April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF
admission.
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer
found based on the documentation provided, the enrollee requires the intensity of services provided at an IRF.
Specifically, the enrollee requires heavily monitored and assisted therapy, as well as regular physician
evaluation. Per the health plan, the enrollee requires ongoing inpatient care. As such, the enrollee's care needs
cannot be met at a lower level of care.
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 been met. Therefore, we decided that the Plan has to pre-approve
acute inpatient rehabilitation facility (IRF) admission and services.
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.