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

We decided that the Plan does not have to pay for emergency room services (99285) provided January 12, 2020.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
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 emergency room services was not filed until September 9, 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 emergency room services (99285) provided January 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mohs micrographic technique (17311) provided on April 15, 2021.
You asked the Plan to pay for the Mohs micrographic technique. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed service is included in the global surgery period for CPT code 15260.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery when furnished by the physician who performs the surgery. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Mohs micrographic technique have not been met. Specifically, the record indicates that this physician furnished a skin graft (15260) on February 18, 2021. CPT code 15260 has a global surgery period of 90 days and this follow up service was rendered within the 90 day global surgery period. Additionally, the provider did not bill this service with the required modifier to indicate that this service was separate and distinct. Therefore, we decided that the Plan does not have to pay for the Mohs micrographic technique (17311) provided on April 15, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and
comprehensive oral evaluation (D0150) provided on May 21, 2021, by an OON provider.
You asked the Plan to pay for the incisional biopsy of oral tissue and comprehensive oral evaluation. You say
that you followed the Plan's recommendations to the letter and see no reason why you should pay for the Plan's
misinformation. The Plan denied your request. The Plan says the incisional biopsy of oral tissue is not covered,
and services performed by an OON provider are not covered because your healthcare plan does not have OON
benefits. The Plan also says that you contacted the Plan on May 13, 2021, and understood that Plan specialists
may offer a 20% discount for services rendered.
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, incisional biopsy of oral tissue
(D7286) is not among those covered under this benefit. You are also responsible for 100% of the cost for dental
services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the
incisional biopsy of oral tissue (D7286) and comprehensive oral evaluation (D0150) provided on May 21,
2021, by an OON provider.
Please Note: The Plan forwarded this appeal information to the medical team for processing under your
medical plan. Please contact the Plan for more information
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided March 11, 2021.
You asked the Plan to pay for the therapeutic services. You say that many of the requested services in 2020 are
not available on an outpatient basis secondary to the recent COvId-19 virus pandemic. The Plan denied your
request. The Plan says the code is not appropriate for service 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 find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the
service was performed by an occupational therapist in a home health or hospice setting. There is a more
appropriate HCPCS (Healthcare Common Procedure Coding System) code (G0152). Based on this
information, we decided that Medicare rules for coverage of the therapeutic services have not been met.
Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided March
11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 191.
You asked the Plan to pay for the inpatient hospital services billed with DRG 191. You say that the diagnoses
are both clinically supported and reportable as secondary diagnoses. The Plan denied your request. The Plan
says that DRG 191 is not supported as the diagnosis of morbid (severe) obesity from excess calories and body
mass index (BMI) 50.0-59.9, adult.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with secondary diagnosis codes, E66.01, defined as
morbid (severe) obesity from excess calories, and Z68.43, defined as Body mass index (BMI) 50.0-59.9, adult.
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 inpatient hospital services billed with
DRG 191. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found that the
medical records did not support the billing of morbid (severe) obesity from excess calories and body mass
index (BMI) 50.0-59.9, adult.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services billed with diagnosis related group (DRG) code 191
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure reducing mattress
You asked the Plan to pre-approve the services. You say that you are being treated for leg ulcers, and the mattress would assist in alleviating pain. The Plan denied your request. The Plan says the doctor's notes do not show that the criteria is met.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have diabetes mellitus with venous stasis ulcers and a foot ulcer. The documentation does not support that you have any stage 2 pressure ulcers located on the trunk or pelvis, and has failed to improve in the previous month with conservative treatment with a comprehensive ulcer treatment program or a myocutaneous flap or skin graft. The requested pressure reducing support surface is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure reducing mattress
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visits rendered on August 30, 2021 to September 13, 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 that payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the post-operative visits are not separately payable, as they are included in the global surgical period; however, there is no documentation of a major or minor surgical procedure for which a global surgical period applies. The file shows that the enrollee received an x-ray of the knee (code 73562) on August 30, 2021 and arthrocentesis (code 20611) on September 13, 2021. The x-ray is not a surgical procedure and code 20611 carries a 0 day global surgical period. The Plan has not provided any documentation to show that the office visits are not payable as billed. Therefore, we decided that the Plan has to pay for the office visits rendered on August 30, 2021 to September 13, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit/consult (99205) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you have been receiving treatment at this provider for over 2 1/2 years. You have tried other providers and was told they were unable to assist you and was referred back to this provider. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit/consult (99205) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring services
provided 95957-TC, 95938-TC, 95908-TC, 95886-TC, 95886-TC provided December 9, 2020.

You asked the Plan to pay for the diagnostic services. You say that the enrollee typically does not request any
type of ancillary services provided during surgery, but those services are provided on the order of the surgeon.

The Plan denied your request. The Plan says the technical component is considered as performed by the facility
and is covered as part of the inpatient stay. The technical component is incidental to the hospital billing and is
not separately 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.

In this case, neuromonitoring services was provided in the facility during surgery. Payment for this service
would have been included under the facility claim. Payment for this service is the responsibility of the facility
or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of
the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the
intraoperative neurophysiologic monitoring services provided 95957-TC, 95938-TC, 95908-TC, 95886-TC,
95886-TC provided December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (procedure code 99205) provided to the
enrollee on August 9, 2021.

You asked the Plan to pay for the services. You say that there are two different specialty doctors and should
have been paid accordingly. The Plan denied your request. The Plan says this is an incorrect procedure code for
an established patient.

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 99205 is "Office or other outpatient visit for the
evaluation and management of a new patient, which requires a medically appropriate history and/or
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of
total time is spent on the date of the encounter."

We find that CPT code 99205 is not supported in the medical record. Specifically, it would not be appropriate
to use a new patient office visit code in this case. An established patient code was billed on September 28,
2020. The enrollee would not be considered a new patient on August 9, 2021. 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 an office visit (procedure code 99205) provided to the enrollee on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health, and home physical therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 4, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the lab services. You say that these services were medically necessary to test the patient for opioid abuse. The Plan denied your request. The Plan says unauthorized, non-plan services are not covered.

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.

You are not a network provider with the Plan. Neither the Plan nor a Plan-contracted provider pre-approved 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 lab services provided on August 4, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the annual physical exam provided on September 23, 2021.

You asked the Plan to pay for the annual physical exam. You say that you would like reconsideration because this service was an annual physical and the last visit was the annual wellness exam. The Plan denied your request. The Plan says that this benefit has been exhausted.

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the annual physical exam have been met. Specifically, the clinical information indicates that the member received an annual wellness exam on January 7, 2021. The records also support that the service at issue was the member's annual physical. Additionally, the Plan has not forwarded a claim or explanation of benefits for the services rendered on January 7, 2021 to confirm what was billed by the provider. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, there is evidence to support that you have not exhausted your benefit for an annual physical exam so we must find in your favor. Therefore, we decided that the Plan has to pay for the annual physical exam provided on September 23, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on June 21, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the
paramedics arrived, they injected the enrollee with something and when the enrollee came around, he asked
what it would cost and was told it would cost nothing. You also say that you believe this service should cost no
more than the traditional ambulance transport fee of $250.00 because the home treatment saved the Plan the
cost of an ambulance transport and an emergency room treatment. The Plan denied your request. The Plan says
an ambulance was called, and the enrollee was not transported to an emergency facility. The Plan also says that
the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then
there is no Medicare covered services.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on June 21, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no
transport (A0998) provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that these are medically necessary for your condition. The Plan denied your request. The Plan says supplies that are purchased over the counter are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 2, 2021, and August 25, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as your previous surgery being done incorrectly caused your current issues. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $25 copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist office visits.

You have been asked to pay a $25 copayment for two specialist office visits. The record indicates that these services were performed by specialists. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visits provided on August 2, 2021, and August 25, 2021.