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

We decided that the Plan does not have to pay for the laboratory services rendered on June 10, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on June 20, 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. The provider in this case is 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 laboratory service (81479) rendered by the out-of-network (OON) provider on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the swallowing dysfunction treatment coded as 92526 
provided on January 16, 2020. 
 
You asked the Plan to pay for the swallowing dysfunction treatment. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says there was a 
more appropriate code that should have been billed for this service. 
 
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 92526 is treatment of swallowing dysfunction and/or oral 
function for feeding. 
 
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 swallowing dysfunction treatment. Our reviewer says that 
the documentation provided does not support the code as billed. Our reviewer found the medical records 
document that service was performed in a home health or hospice setting. 92526 GN KX is not the most 
appropriate code to use to bill this service; therefore, this service is not eligible for reimbursement 
consideration. There is a more appropriate Healthcare Common Procedural Coding System (HCPCS) code that 
should be used to bill 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 the swallowing dysfunction treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for the swallowing dysfunction treatment coded as 92526 provided on 
January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (44955) provided on April 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this add-on code was not billed with an appropriate primary procedure code.
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 44955 is an add-on code and has not been billed with an appropriate primary procedure code. 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 services (44955) provided on April 26, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis to be provided by an OON provider. 
 
You asked the Plan to pre-approve the OON dialysis services. You say that the requested OON provider is 
downstairs from your kidney doctor and their hours work for you. You say that you are not comfortable 
switching facilities and that if you did you would also need to change your kidney doctor, which you don't want 
to do. The Plan denied your request. The Plan says there are in-network dialysis facilities in your service area 
that can treat you immediately. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dialysis to be provided by an OON provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on October 3, 2020.
You asked the Plan to pay for the fixed wing air transport and mileage. You say that you would like payment to be allowed for these services. The Plan denied your request. The Plan says that the information provided does not support criteria for air ambulance transport.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 fixed wing air transport and mileage. Our reviewer says that the elements of the coverage criteria are satisfied. Our physician reviewer found the record indicates that the enrollee has a history of a heart transplant and had chest pain. The enrollee was diagnosed with sepsis, Non-ST-elevation myocardial infarction (NSTEMI) and congestive heart failure. The record documents that the enrollee has three vessel coronary disease as well as a reduced ejection fraction, concerning for transplant rejection. Our reviewer found that in this case, the record provided indicates that the enrollee was on intravenous heparin and required heart transplant evaluation or treatment of rejection. Intravenous heparin requires ambulance crew services. Heart transplant rejection requires immediate evaluation and is a threat to life. Our physician reviewer also found that the distance to the transplant hospital precludes ground transportation. 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 fixed wing air transport and mileage have been met. Therefore, we decided that the Plan has to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on October 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 X 
11), for the enrollee. 
 
You asked the Plan to pre-approve home health physical therapy visits. You say that the enrollee would 
continue to benefit from skilled physical therapy to address areas of deficit. The Plan denied your request. The 
Plan says they previously approved visits to teach the enrollee and their caregiver(s) a home exercise program. 
The Plan states the enrollee's records suggest that continuing this exercise program should help the enrollee 
maintain their level of function or improve further. The Plan states the enrollee does not show that additional 
home physical therapy visits are needed for this to occur. The Plan states the enrollee's records do not support 
the need for a skilled physical therapist to make more home visits at this time. 
 
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 home health physical therapy visits. 
Our physician reviewer found the documentation does not support that the enrollee requires additional skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve the 
enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The enrollee has received adequate services to establish a home exercise program 
for the enrollee and their family. The requested home health services 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 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 X 11), for the 
enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care coded as 99225 provided on May 25, 2021.
You asked the Plan to pay for the subsequent observation care. You say that the services were coded correctly based on the documentation. The Plan denied your request. The Plan says the provider should submit a corrected claim for reconsideration.
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 99225 is subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 subsequent observation care. Our reviewer says that the documentation provided does not support the code as billed. Our reviewer found in this case services were incorrectly billed. Visit note documents a "Nephrology consulted for dialysis management" per visit note. Patient status is observation care for post fall. A consult should be reported with an appropriate established office or other outpatient visit codes. 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 subsequent observation care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent observation care coded as 99225 provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the RFA services. You say that the records provided support the need for
the requested services. The Plan denied your request. The Plan says it is not medically necessary to have the
requested procedure at the sacroiliac joint.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the RFA services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has chronic low back pain. The enrollee has found heat, Advil, home
exercise and rest are helpful in dealing with his pain. The appellant has had prior Transforminal Epidural
steroid injections as well as sacroiliac (SI) joint injections prior to RFA of the SI joints. RFA of the SI joint is
considered experimental/investigational because of the wide variation in efficacy reported in the literature.
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 RFA services have not been met.
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided April
26, 2021, to May 4, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were not aware
you would be charged a copayment you cannot afford. The Plan denied your request. The Plan says the
copayment has processed
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 $290
copayment for days 1-7 and a 0$ copayment for each additional day for inpatient hospital care.
You have been asked to pay a total cost share of $2030 for the inpatient hospital care ($290 copayment x 7
days). These services fall 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. 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 inpatient hospital care provided April 26, 2021, to May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on May 6, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is a guideline recommended service. The 
Plan denied your request. The Plan says this was not ordered by the ordering physician. 
 
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 say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment.  
 
We find that CPT code 81479 is not supported in the medical record. Specifically, no medical records 
documenting this service have been submitted. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory services (81479) provided on May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray (71045) provided on June 2, 2021.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray (71045) provided on June 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need physical therapy and if you do not get physical therapy you will not regain maximum function in your legs and may be unable to walk in the future. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with a urologist you had on
November 9, 2020.
You asked the Plan to waive the copayment for the urology visit. You say that this service was just to get a
prescription refill. You stated that you have never had to pay for this. The Plan denied your request. The Plan
says you were charged this copayment correctly. The Plan says that because the allowed amount for this
service ($49.93) is less than your copayment obligation, you are responsible for the full allowed 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 $50
copayment for visits with a specialist.
You have been asked to pay a $50 copayment for the urology visit. This copayment applies to any visit with a
specialist, regardless of the reason for the visit. 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 visit
with a urologist you had on November 9, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you will not be able to walk without rehabilitation services and may be crippled and bed ridden. You state your calf muscles are weak. You state you are not able to walk and home health services will not be enough to help to recover. The Plan denied your request. The Plan says that your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF. The Plan states your rehabilitation and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by your health plan and your rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our physician reviewer found you do qualify for SNF coverage. You do not have documented skilled nursing needs. You do have documented skilled therapy needs. You are functioning below her reported baseline. The documentation does not yet establish that you have reached a new plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of you condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on May 11, 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 procedure code 97530 is not supported.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code. 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 pay for the occupational therapy services rendered on May 11, 2021.