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

We decided that the Plan does not have to pay for the services coded 36140, 75710, and 75774 billed with Modifier -59 provided March 31, 2021.
You asked the Plan to pay for the services coded 36140, 75710, and 75774. You say that these services are supported in the medical records. The Plan denied your request. The Plan says these codes are included in the payment for other codes.
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 services coded 36140, 75710, and 75774 Our reviewer says that the records do not support that the billed codes 36140, 75710, and 75774 were distinct procedural services. Our physician reviewer found that the enrollee is a 60-yr old who received services on March 31, 2021 for Current Procedural Terminology (CPT) 36140 Introduction of needle or intracatheter, upper or lower extremity artery, Current Procedural Terminology (CPT) 75710 Angiography, extremity, unilateral, radiological supervision and interpretation, and Current Procedural Terminology (CPT) 75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure). Documentation submitted was reviewed, and the criteria for coverage have not been met. The billed codes 36140, 75710, and 75774 would not be reported separately with modifier 59. These procedures were unbundled from CPT 37228, and therefore would not be covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services coded 36140, 75710, and 75774 have not been met. Therefore, we decided that the Plan does not have to pay for the services coded 36140, 75710, and 75774 billed with Modifier -59 provided March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 3, 2020, through March 7, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you did not have a choice 
about your hospital room status. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
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 $250 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $1000 ($250 x 4 = $1000) copayment for inpatient hospital care. The services at 
issue 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 inpatient hospital care provided from March 3, 2020, through March 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction provided on May 12, 2021.

You asked the Plan to pay for determination of refractive state (92015). You say that eye refraction is part of
your coverage. The Plan denied your request. The Plan says the refraction was a medical vision check and not
covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers eye refractions during a routine exam provided by a preferred provider.

We looked at the file and the Plan's rules. The diagnosis codes show that this was a medical exam not a routine
exam. Based on this information, we decided that the Plan's rules for coverage of determination of refractive
state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for refraction
provided on May 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you are walking now but
your leg is still weak, and you need a cane. You say that more sessions would allow you to walk without the
use of a cane and coverage should be reconsidered. The Plan denied your request. The Plan says additional
visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that you had prior extensive therapy and
have been instructed in a home exercise program. Our reviewer says that the unique skills of a professional
therapist are not required to safely and effectively provide ongoing treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78608) provided on April 23, 2021.
You asked the Plan to pay for a PET scan. You say that this diagnosis is appropriate for the enrollee's symptoms. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. We looked at the file and Medicare rules. The billed diagnosis code, R41.3, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78608) provided on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045-26) provided to the enrollee on March 25, 2021.

You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Review of the records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 71045 and 36556. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the chest x-ray (CPT code 71045-26) provided to the enrollee on March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on April 15, 2021 by an out-of-network provider.
You asked the Plan to pay for debridement (11042, 11043) and chemical cauterization of granulation tissue (17250). You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications. The Plan denied your request. The Plan says you did not obtain prior authorization as required. 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for wound care provided on April 15, 2021 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray interpretation provided on March 14, 2021.

You asked the Plan to pay for the chest x-ray (71045-26) interpretation. You say that the services were done at different times for different reasons. The Plan denied your request. The Plan says the code is payable only if a clinically appropriate National Correct Coding Initiative (NCCI) modifier is used.

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. 

Specifically, code 71045 was not billed with modifier 59 to allow for separate payment. The same service, by same provider, on the same date, was paid on March 23, 2021. Based on this information, we decided that Medicare rules for coverage of services billed without a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray interpretation provided on March 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81401, 81403, 81404,
81405 and 81406) provided to the enrollee on October 3, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. Medicare guidance says
Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or
documented cardiovascular disease (CPT Code(s): 81405 and 81406).
CPT code 81401-90-XS (1 Unit), CPT code 81403-90-XS (2 Units) and CPT code 81404-90-XS (2 Units)
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting POS 11. Of note, the patient resides in a different state than the billing
laboratory; therefore, the billed code cannot be verified. Therefore, we decided that the Plan
does not have to pay for the laboratory services (CPT code(s): 81401, 81403, 81404, 81405 and 81406)
provided to the enrollee on October 3, 2020.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says an IRF stay is not medically necessary. The Plan says that the enrollee's needs can be met with short term lower level of care.
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 form elective total hip replacement. 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 a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (12013) provided to the enrollee on April 30, 2018.
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 an appropriate modifier was not billed in this case.
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 12013 is "Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes." 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 the provider billed for CPT 12013 and CPT 12002. When these codes are billed together, the appropriate modifier should be appended. NCCI-associated are used to indicate the special circumstances such as when the procedures are performed at different anatomic sites, a separate procedure or repeat clinical diagnostic laboratory test. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together. Without the appropriate modifier, this code 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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (12013) provided to the enrollee on April 30, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the injection procedure you had at an out-of-network hospital on June 4, 2021.
You asked the Plan to reduce the coinsurance for the injection procedure. You say that in the past, this procedure has only cost you about $500. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
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 50% coinsurance for services at an out-of-network outpatient hospital facility. You have been asked to pay 50% coinsurance for the injection procedure. The injection procedure falls within the services at an out-of-network outpatient hospital facility 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 reduce the coinsurance for the injection procedure you had at an out-of-network hospital on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (L0650) provided on March 18, 2021.
You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that you did not ask for the item at issue and are not allowed to return it. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for durable medical equipment. You have been asked to pay $139.68, or 20% of the Medicare-allowed charge of $698.41, for a lumbar-sacral orthosis. A lumbar-sacral orthosis falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis
(L0650) provided on March 18, 2021.
Your complaint about receiving services you do not or do not want to pay for 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stimulator device (64555, L8679).
You asked the Plan to pre-approve the stimulator device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is not covered.
The Plan must follow Medicare rules. Medicare rules say that any ear or auricular electrical devices (e.g., DYANSYS) are also non-covered by Medicare as electrical acupuncture. We looked at the file and Medicare rules. The device requested is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve a stimulator device (64555, L8679).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an unlisted laboratory test (81479) provided on November 10, 2020.
You asked the Plan to pay for an unlisted laboratory test. You say that this should be covered as in-network. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that when billing for unlisted laboratory tests using a not otherwise classified (NOC) code, field 19 of the claim must include the specific name of the laboratory test(s) and/or a short descriptor of the test(s). We looked at the file and Medicare rules. The specific name of the laboratory test was not listed in field 19 of the claim form. Based on this information, we decided that Medicare rules for coverage of an unlisted laboratory test have not been met. Therefore, we decided that the Plan does not have to pay for an unlisted laboratory test (81479) provided on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on February 13, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Therefore, the billed
service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. 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 hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ultrasound and injection provided on
March 22, 2021.

You asked the Plan to waive the coinsurance for the complete joint ultrasound (76881) and injection (J1100,
J1030). You say that an ultrasound and injection was not done during this visit. The Plan denied your request.
The Plan says you were charged the coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs and for Outpatient diagnostic tests.

You have been asked to pay 20% coinsurance for the complete joint ultrasound (76881) and injection (J1100,
J1030). The medical record confirms the services were performed. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
coinsurance for the ultrasound and injection provided on March 22, 2021.