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

 We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided May 6, 2021, to May 7, 2021  You asked the Plan to pay for the subsequent hospital care. You say that please review the attached medical records to substantiate the diagnosis code billed. Kindly review and reprocess the claim for payment of the professional services performed. The Plan denied your request. The Plan says the diagnosis billed is not valid as a primary diagnosis.  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 99232 is subsequent hospital 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.  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 hospital care. Our reviewer says that the records do not support that this service was billed correctly. Our reviewer found the enrollee received inpatient hospital services on May 6, 2021, through May 7, 2021, for primary diagnosis ICD 10 R65.10: Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction. The documentation submitted was reviewed and does not meet criteria. Per CPT guidelines, the code for SIRS should never be sequenced as a principal diagnosis, therefore this service was reported incorrectly, and would not be covered.  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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided May 6, 2021, to May 7, 2021
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a laparoscopy, surgical procedure with removal of adnexal structures (58661).  You asked the Plan to pre-approve a surgical procedure. You say that the requested surgical procedure is medically necessary The Plan denied your request. The Plan says Medicare will cover this procedure only when it is needed as a necessary part of treatment of an injury or illness. It is not covered for prevention of pregnancy.    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 a surgical procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is being performed for sterilization purposes. The provided record does not sufficiently establish that the requested procedure is being performed for another medical condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a laparoscopy, surgical procedure with removal of adnexal structures (58661).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 24, 2021, to March 25, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee does not require daily skilled services on an inpatient basis.  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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  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 SNF care have not been met. Specifically, the file does not indicate that the enrollee received skilled services on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 24, 2021, to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial inpatient hospital care (99223) provided August 4, 2019.  You asked the Plan to pay for the hospital care. You say that due to no fault of your own, the claim was billed to the insurance after the timely filing limit. You request reconsideration of the denial and process the submitted claim for payment. The Plan denied your request. The Plan says this claim was submitted past the timely filing limitation.  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 hospital care was not filed until May 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial inpatient hospital care (99223) provided August 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found There is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided on January 6 to May 19, 2021, by a provider not enrolled in the Medicare program.  You asked the Plan to pay for psychotherapy services. You say that the provider informed you that their services are covered by the Plan. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on January 6 to May 19, 2021, by a provider not enrolled in the Medicare program.   Your complaint about receiving erroneous or incomplete information about your benefits from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for neurophysiology services (procedure codes 95938, 95967, G0453) provided to the enrollee on February 16, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says billing these services separately represents a duplication of effort and an overlap of 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.  In this case, the CPT Code Manual definition of the denied codes is:  CPT 95938:  Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs  CPT 95967:  Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (eg, sensory, motor, language, or visual cortex localization) (List separately in addition to code for primary procedure)  HCPCS G0453:  Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found per the documentation, these codes have been previously paid to the facility, as the technical component would be provided by the facility, and the professional component would be covered to the outside provider.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiology services (procedure codes 95938, 95967, G0453) provided to the enrollee on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services rendered on January 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 procedure code 99292 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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).     We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of an additional 30 minutes of critical care time. 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 critical care services rendered on January 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging service (78452) provided on March 13, 2020.  You asked the Plan to waive the copayment for the nuclear medicine study. You say that you were shocked to receive a bill from 2020 and state that the providers have been having continuous issues with receiving payments from the Plan. You also say that the provider is considering discontinuing acceptance of your insurance which means you would lose your cardiologist. You expressed a desire to get immediate attention to this matter. The Plan denied your request. The Plan says the cost-share was applied correctly in accordance with your benefits.  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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays.   You have been asked to pay a $160 copayment for the nuclear medicine study. Nuclear medicine studies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The provider billed the service at $800, but the Plan only allows for $320.28 to be billed for this service. Furthermore, the Plan paid $157.08.  $320.28 (Allowed Amount) - $157.08 (Plan Paid) = $163.20   Since the remaining amount of $163.20 is greater than the required copayment, you are only charged the lesser amount of $160. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging service (78452) provided on March 13, 2020.   Your complaint about potential billing issues and the possibility of losing your providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. The Plan states this grievance is being addressed on another case. Medicare does not permit us to make a decision about these types of complaints. Please contact the Plan for further information regarding this matter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental services with an out-of-network dental provider.  You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says out-of-network services are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The Plan only covers dental services provided by network providers. Out-of-network dental services are not covered. Therefore, we decided that the Plan does not have to pre-approve dental services with an out-of-network dental provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that the wheelchair would provide aid to the enrollee on a daily basis. The Plan denied your request. The Plan says the enrollee does not meet criteria.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   We looked at the file and the rules. The medical records provided show that the enrollee would not need the chair for in the home. The enrollee is able to use a cane or walker. The records do not show that the enrollee's home provides adequate access for the operation of a power wheelchair. Based on this information, we decided that the Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a wrist-hand orthosis (L3908) provided on May 10, 2021.  You asked the Plan to pay for a wrist-hand orthosis. You say that the requested item was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. 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 a wrist-hand orthosis (L3908) provided on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.      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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), crown - porcelain/ceramic (D2740), and unspecified preventive procedure, by report (D1999) provided June 23, 2021.  You asked the Plan to pay for the core buildup, crown and unspecified preventative procedure. You say that you were not told the full cost of the services. The Plan denied your request. The Plan says these services are not covered under your benefits.  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 core buildup, including any pins when required (D2950), crown - porcelain/ceramic (D2740), and unspecified preventive procedure, by report (D1999) provided June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on April 26, 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 were not urgent or emergent and provided by an out-of-area provider without prior authorization.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.    We looked at the file and Medicare rules. The file shows that the services were performed for right-sided facial swelling that had been present for six weeks. The services were not for an unforeseen illness or injury. 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 office visit rendered on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office consultation (99244) and outpatient office visits (99214) provided on July 15, 2021 to August 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visits. You say that all of your doctors agree that you are a perfect candidate for this doctor as he is a specialist in complex cases like yours. If you are denied you have exhausted all of the doctors here and do not know where else to turn. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 consultation (99244) and outpatient office visits (99214) provided on July 15, 2021 to August 19, 2021 by an out-of-network (OON) provider.