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

We decided that the Plan does not have to pay for the surgical endoscopy coded as 33508-59 provided on January 28, 2021.
You asked the Plan to pay for the surgical endoscopy. You say that the medical documentation supports billing this claim as being a distinct procedural services. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 the surgical endoscopy Our reviewer says that the requested service does not meet criteria for coverage as billed. Our physician reviewer found the documentation does not support billing CPT 33508 separately from the primary procedure. Modifier 59 is used to distinguish a different session, different procedure, surgery, or different anatomical site. Therefore, this procedure would not be covered separately.
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 surgical endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the surgical endoscopy coded as 33508-59 provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on February 23, 2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for February 23, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the billed codes 95957, 95908, and 95886 provided on October 19, 2020.

You asked the Plan to pay for the billed codes 95957, 95908, and 95886. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says the billed codes are not supported in the medical records submitted.

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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (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 billed codes 95957, 95908, and 95886. Our reviewer says that the medical records do not support the codes as billed. Our reviewer found the medical records provided do not include sufficient documentation to support that a Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) was performed on October 19, 2020 as pedicle screw stimulations do not meet criteria of baseline nerve conduction studies.

Regarding code 95908 our coder found that the medical records provided do not include sufficient documentation to support that this procedure was performed as pedicle screw stimulations are not baseline nerve conduction studies. Therefore, this service cannot be verified. 

Finally regarding code 95886, the medical records provided do not include sufficient documentation to support that a Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) was performed on October 19, 2020, therefore this procedure cannot be verified. A real time Electroencephalogram monitoring is not covered under CPT code 95957. 

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 billed codes 95957, 95908, and 95886 have not been met. Therefore, we decided that the Plan does not have to pay for the billed codes 95957, 95908, and 95886 provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of missing or broken teeth (D5520) provided
on May 19, 2021.
You asked the Plan to pay for the replacement of missing or broken teeth. You say that the tooth is important
for chewing food properly. You also say that it is important for your self-esteem and social interaction. The
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
replacement of missing or broken teeth (D5520) provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ipilimumab injection 1 mg for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of metastatic urothelial carcinoma. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Ipilimumab injection 1 mg for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 70450 provided on May 7, 2021.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 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 computed tomography (CT) scan represented by code 70450 provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 13 or more nerve conduction studies represented by code 95913 and Needle electromyography represented by code 95886 provided on March 23, 2021.
You asked the Plan to pay for codes 95913 and 95886. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, the CPT Code Manual definition of code 95913 is Nerve conduction studies; 13 or more studies. We find that CPT code 95913 is not supported in the medical record. Specifically, the record shows there were less than 13 nerves studied in this case. There is a more appropriate code that should be used to bill for this service. Code 95886 is not covered in this case, because the primary code, 95913, is not covered. Add-on code 95886 cannot be paid separately. Based on this information, we decided that Medicare rules for coverage of codes 95913 and 95886 have not been met. Therefore, we decided that the Plan does not have to pay for 13 or more nerve conduction studies represented by code 95913 and Needle electromyography represented by code 95886 provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product represented by dental code D7921 provided on March 31, 2021.
You asked the Plan to pay for dental code D7921. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D7921 is not covered by Medicare or the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product represented by dental code D7921 provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you cannot bend your knees. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for C. Taylor, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on April 19, 2021.

You asked the Plan to pay for the mandibular partial denture. You say that the bottom denture you received in 2019 did not fit in your mouth. You also say that you tried to have it adjusted multiple times, but it never fit. The Plan denied your request. The Plan says this service exceeds the maximum could allowed per period.

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, mandibular partial denture (D5214) is limited to one procedure every five plan years. The record shows that you received a mandibular partial denture (D5214) on July 9, 2019 and your mandibular partial denture (D5214) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on November 9, 2020.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for November 9, 2020 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 8, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the drug testing services provided on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs acute rehabilitation approved because he is currently in the hospital and needs physical therapy to help him walk, needs to build his endurance and strength, and because he has been bed bound. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, pneumonia, and a urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81201, 81317, 81403, 81404,
and 81405 provided on June 17, 2020.

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 codes 81201, 81317, 81403, 81404, and 81405 are not supported in the medical record.
Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a
laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting place of service 11. 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 81201, 81317, 81403, 81404, and 81405 provided
on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive this copayment.

You asked the Plan to waive this copayment. You say that you do not agree with this copayment because the doctor only saw you for five minutes. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement and the claim submitted by your provider.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The contract with the Plan clearly says that enrollees must pay $45 copayment for specialist services. You have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have waive this copayment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for therapeutic injections (62321) provided on April 13 and May 4, 2021.

You asked the Plan to waive the copayments for therapeutic injections. You say that the procedures at issue were outpatient procedures and should not be coded as emergency room visits. The Plan denied your request. The Plan says the correct copayments were applied.

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 $100 copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center.

You have been asked to pay $200, or a $100 copayment per date of service, for therapeutic injections. Therapeutic injections fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 copayments for therapeutic injections (62321) provided on April 13 and May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6751 x 2), pontic (D6241), the consultation (D9310), extraction (D7210), guided tissue regeneration (D4266), and bone replacement graft (D7953) provided from May 12, 2021, to May 14, 2021.
You asked the Plan to pay for the dental services. You say that you needed a new crown. You say that you called the plan to see if it would be covered. You say that a plan representative advised you were covered for a crown with a 50% copayment. You say that your doctor advised the crown could not be replaced so you needed a bridge. You also say that you cannot afford to pay any more money. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that retainer crowns and pontic are not listed as covered services. The Plan also says that the consultation, extraction, tissue regeneration, and bone graft are not listed as covered services either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6751 x 2), pontic (D6241), the consultation (D9310), extraction (D7210), guided tissue regeneration (D4266), and bone replacement graft (D7953) provided from May 12, 2021, to May 14, 2021.
Your complaint about being misled by a plan representative 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.