Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) provided on August 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed based on medical necessity of the services provided. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 office visit (99213) provided on August 12, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on December 30, 2020.

You asked the Plan to pay for air ambulance services provided on December 30, 2020. The Plan denied your
request. The Plan says air ambulance services were not medically necessary.

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 air ambulance services provided on
December 30, 2020. Our reviewer says that the air ambulance transport was not medically necessary. Our
physician reviewer found that the enrollee is a 66-year-old female who was transported via air ambulance from
hospital to hospital for stroke care. Ground transportation to the nearest appropriate hospital was 62 minutes
and air transport was 33 minutes. The enrollee's vitals prior to transport were BP135/81, P69, R18, 100%,
Glasgow 15. Deficits in left extremities was noted. She was alert and oriented. The documentation does support
that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than
ambulance. Cerebral vascular accident (CVA), but stable. The documentation does not support that the
enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by
ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The enrollee was
hemodynamically stable, oriented, and alert without distress. She would have been safe to transport via ground
transport. The documentation does support that the transferring hospital did not have adequate facilities to
provide the medical services needed by the enrollee or that specialized CVA care needed was only available at
the receiving hospital.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for air ambulance services provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81230, 81231, 81232, 81355, 81381, 81240, 81241, 81283, 81328, 81335, and 81350 provided on July 16, 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 billed are not 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.  We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81232, 81355, 81381, 81240, 81241, 81283, 81328, 81335, and 81350 are not supported in the medical record. Specifically, molecular pathology testing was completed. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file shows that one code was not submitted for the panel provided. 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, 81230, 81231, 81232, 81355, 81381, 81240, 81241, 81283, 81328, 81335, and 81350 provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant Reveal testing rendered on August 14, 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 the testing was performed for surveillance screening.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, Guardant Reveal, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Guardant Reveal testing rendered on August 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department (ED) visit (99283) and self-administered drugs (A9270) provided on July 24, 2021.  You asked the Plan to pay for the ED visit and self-administered drugs. The Plan denied your request. The Plan says the enrollee was actively enrolled in hospice on this date of service.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.      The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the emergency department (ED) visit (99283) and self-administered drugs (A9270) provided on July 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 2, 2020, to March 7, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this was Covid-19 related, and you should not be charged. The Plan denied your request. The Plan says the correct copayment has been 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 $295 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $295 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,475 ($295 x 5 days = $1,475). The correct copayment has been applied to the services that were provided. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 2, 2020, to March 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services rendered on January 20, 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 the services are not covered.  The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.  We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on January 20, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on July 23, 2021.  You asked the Plan to pay for the emergency department visit. 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.  In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and 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 presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.   We find that CPT code 99284 is not supported in the medical record. Specifically, this code was billed with T37.0X5A (Adverse effect of sulfonamides, initial encounter) as the only diagnosis code on the claim. There is a list of underlying condition diagnosis codes that must be specifically coded first. One of those diagnoses was not billed first Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuromonitoring services (95885, 95908, 95937) provided July 27, 2020.  You asked the Plan to pay for neuromonitoring services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 95885, 95908, & 95937 are not supported in the medical record. Specifically, the medical records indicated the use of pedicle screws, which are not baseline nerve conduction studies and are not covered under CPT code 95908. The medical records submitted indicate Train of Four testing was performed. Train of Four testing is not represented by CPT 95937. Therefore, it is inappropriate to use 95937 to bill for this testing. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95885, 95908, 95937) provided July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services rendered on June 18, 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 the claim is a duplicate.  The Plan must follow Medicare rules. The 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 file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 anesthesia services rendered on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee.    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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the services are medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.

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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental at this time. More research is needed to show safety and efficacy. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic services coded as 97530 provided on May 4, 2021.  You asked the Plan to pay for the therapeutic services as coded. You say that you would like this claim reprocessed for payment based on the medical documentation. The Plan denied your request. The Plan says insufficient documentation was provided to corroborate the services 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.  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 therapeutic services as coded. Our reviewer says that the medical records do not support the code as billed. Our reviewer found a certified occupational therapist assistant (COTA) visit documents that the patient is homebound, and services were performed in the home. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for services performed in the home. CPT 97530 would not be covered based on the documentation submitted.  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 therapeutic services as coded have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic services coded as 97530 provided on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Purewick external catheters and urine collection accessory kits.  You asked the Plan to pre-approve a Purewick system. You say that the records provided support the need for the items in dispute. The Plan denied your request. The Plan says neither they nor Medicare cover the requested items.  The Plan must follow Medicare rules. Medicare rules say that PDAC determinations are evidence of the correct coding of an item.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Purewick system have not been met. Therefore, we decided that the Plan does not have to pre-approve Purewick external catheters and urine collection accessory kits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on August 16, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that your residence staff made you go to the hospital and you feel that they should pay the bill. The Plan denied your request. The Plan says you have been 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 $90 copayment for each emergency room visit. 

You have been asked to pay a $90 copayment for the ER visit. ER visits fall within the Emergency 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 an emergency room (ER) visit provided on August 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services (A0427 and A0425) provided on March 28, 2021.  You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because these services should be covered. The Plan denied your request. The Plan says this claim was filed outside of the Medicare timely filing guidelines.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the ambulance services was not filed until August 5, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Additionally, because these services were rendered out-of-network, neither you nor the Plan should be held responsible for the balance billing. Of note, the Plan has not held you liable for these services. Please contact the Plan if you believe you are being balance billed by the provider. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0427 and A0425) provided on March 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met.  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 that the enrollee does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs are noted in the record. At the current high functional level, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and rehab nursing needs in addition to high functional level.  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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on August 10, 2021.  You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is missing documentation required for payment that sufficiently documents the member's medical condition.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, there is no documentation that shows the provider discussed with the enrollee the medical necessity of the provided equipment. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on August 10, 2021.