Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for initial hospital care (CPT code 99223) provided to the enrollee on May 28, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is 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.  In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  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 service. Our reviewer found documentation submitted was reviewed and does not meet criteria. Documentation supports one evaluation and management service was provided on May 28, 2021, at 19:20, which one unit of service should be billed and paid. As, no documentation was submitted to support two (2) claims were submitted for this service, and one was reimbursed, duplicate billing cannot be verified.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (CPT code 99223) provided to the enrollee on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided the Plan does not have to pay for a manual wheelchair and lift chair purchased on August 4, 2021.  You asked the Plan to pay for this equipment. You say that this equipment was medically necessary. The Plan denied your request. The Plan says you did not have prior authorization and this provider is not a Medicare eligible provider.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a vendor who is not a Medicare eligible provider.   This equipment was purchased without prior authorization from a provider who is not a Medicare eligible provider. The provider indicated you were made aware of this prior to the purchase. You did not follow your Plan contract rules when you purchased this equipment. Therefore, we decided that the Plan does not have to pay for a manual wheelchair and lift chair purchased from All Star Medical on August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.

You asked the Plan to pre-approve Eliquis. You say that this requested drug is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.

Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for progressive lenses and polycarbonate lens received on May 15, 2021.  You asked the Plan to pay for the services. You say that the Plan denied your request. The Plan says the claim was processed correctly.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.   The services you asked the Plan to pay for are considered routine vision services or eyewear. The types of lenses denied in this case are not covered. Therefore, we decided that the Plan does not have to pay for progressive lenses and polycarbonate lens received on May 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasonic guidance (76942) provided on May 22, 2021.  You asked the Plan to pay for ultrasonic guidance. You say that this is supported in the records. The Plan denied your request. The Plan says this 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, we have confirmed that code 76942 is a column II code to column I code 76937. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for ultrasonic guidance (76942) provided on May 22, 2021.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to pay for emergency care provided by a freestanding emergency department on October 5, 2020.  You asked the Plan to pay for emergency care. You say that the facility is trying to charge you, but you have Medicare coverage at this time. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this facility is a standalone emergency room and is not enrolled in Medicare.  The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. Medicare rules state that a hospital-affiliated freestanding emergency department may participate in Medicare during the COVID-19 public health emergency with no requirement to submit a separate enrollment application to Medicare.  We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. While it is true that a freestanding emergency department would not normally be covered by Medicare, Medicare allows hospital-affiliated freestanding emergency departments to participate in Medicare during the COVID-19 public health emergency (which includes October 5, 2020). This freestanding emergency department is hospital-affiliated; therefore, this provider is covered by Medicare without the need to separately enroll in Medicare. Therefore, we decided that the Plan has to pay for emergency care provided by a freestanding emergency department on October 5, 2020.   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, abdomen and pelvis (74177)
provided August 8, 2021.

You asked the Plan to pay for the diagnostic services. You say that records attached supporting that this
procedure was performed by your provider. Claim denied as a duplicate in error. The Plan denied your request.
The Plan says claim already processed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, we find that CPT code 74177 is not supported in the medical record. Specifically, the records show
that this claim was already approved and paid on check dated August 18, 2021. 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 computed tomography, abdomen and pelvis (74177) provided August 8,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on February 23, 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 codes 20550 and J2001 are 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 20550 is injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia"). The definition of code J2001 is injection, lidocaine hcl for intravenous infusion, 10 mg.  

We find that CPT codes 20550 and J2001 are not supported in the medical record. Specifically, there is no documentation of an injection of a single tendon sheath to support code 20550. 

There is no documentation of 10 mg lidocaine for intravenous infusion to support code J2001. 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 surgical services rendered on February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on October 12, 2019.  You asked the Plan to pay for the services. You say that the DRG adjustment should be reconsidered. The Plan denied your request. The Plan says reasonable clinical support within the health record must be present for the diagnosis.  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.    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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee was admitted to the hospital with urinary tract infection, hypotension, and sepsis as a listed diagnosis. He was treated with fluids and antibiotics. He had intermitted hypotension, however, was not showing persistent hemodynamically instability and did not have clear signs of organ dysfunction as a result of the infection to support the sepsis diagnosis. Therefore, the DRG 871 is not supported.   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 inpatient hospital services provided to the enrollee on October 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services (90837) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve psychotherapy services. You say that this exception is necessary for the enrollee's condition. The Plan denied your request. The Plan says since the services being rendered appear to continue to be telehealth, an in-network provider that can see the enrollee in person is not necessary.
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 psychotherapy services (90837) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care could be had at a different kind of facility.

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 pre-approve the admission. Our reviewer says that the requested continuation of services is not medically reasonable or necessary. Our physician reviewer found at the time of transfer into the COVID-19 unit at the skilled nursing facility for isolation, the enrollee was medically stable. She did not require any supplemental oxygen or parental medications specific for infection with COVID-19. The enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. The enrollee was noted to be at or near her functional and medical baseline. The enrollee did not have any parental medication, complex wound care or nutrition given via a feeding tube. She was medically stable without any acute exacerbations of chronic medical problems. Admission to a SNF for inpatient skilled care was not medically necessary. The enrollee required quarantine without skilled care and could have been treated at a lower level of care. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lumbar spine without contrast (72148) provided on June 18, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $180 copayment for in-network advanced imaging services. Additionally, your in-network maximum out-of-pocket amount is $7,550.  This is the most you pay during the calendar year for covered Medicare Part A and Part B services received from a network provider.  You have been asked to pay a $180 copayment for the in-network advanced imaging service provided. You had not previously met the in-network maximum out-of-pocket amount for this calendar year. 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 magnetic resonance imaging (MRI) of the lumbar spine without contrast (72148) provided on June 18, 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  

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 necessitating admission to a LTACH. 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 present setting where he 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.  

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for therapy services (97110, 97116) provided from March 15, 2021, to March 31, 2021.  

You asked the Plan to waive the copayment for therapy services. You say that you were told by an attorney that there has been an Executive Order since March 18, 2020, that an insurance company cannot deny a claim if their treatment was based on the fact the individual had the coronavirus (Covid-19). You also say that the enrollee would have never been in the nursing facility if he had never contracted Covid-19. The Plan denied your request. The Plan says you were 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 when your stay is no longer covered, physical therapy, speech language therapy, and occupational therapy will be covered according to the Outpatient Rehabilitation Services benefit category.  The Plan contract also says that enrollees must pay a $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit.   

You have been asked to pay a $40 copayment for each visit of therapy services for 14 days ($40 copayment x 14 days =$560). Therapy services falls within the for each Medicare-covered physical therapy and speech-language therapy visit 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 therapy services (97110, 97116) provided from March 15, 2021, to March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology examination of tissue using a microscope,
intermediate complexity (CPT code 88305) provided to the enrollee on June 30, 2021.
You asked the Plan to pay for the service. You say that the enrollee had multiple exams on this date of service.
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 service have not been met. Medicare coding rules indicate the
CPT code 88305 is found under Column Two of the edit pair CPT code 17313 found under Column One. 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 and Column two code is denied as the
mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same beneficiary
encounter. We find that the Medicare rule for payment of this claim has not been met. Therefore, we decided
that the Plan does not have to pay for pathology examination of tissue using a microscope, intermediate
complexity (CPT code 88305) provided to the enrollee on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder Detect testing provided on April 14, 2021.  You asked the Plan to pay for the CxBladder Detect panel. You say that this is now covered by Medicare. The Plan denied your request. The Plan says this remains experimental at this time.  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 pay for the CxBladder Detect panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found CxBladder is considered experimental/investigational as a screening test for urothelial cancer.  Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective validations are needed to confirm these findings.   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 CxBladder Detect panel have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect testing provided on April 14, 2021.