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

 We decided that the Plan does not have to pay for the epidural steroid injection (62320) provided July 26, 2021.  You asked the Plan to pay for the outpatient services. You say that the procedure you are billing for is subarachnoid injection of opioid medications. You are appealing the Plan's denial to pay. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the 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 code 62320 is injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic.  We find that CPT code 62320 is not supported in the medical record. Specifically, medical records were not provided to support the billed services. The Plan made multiple attempts to obtain the medical records from the provider without success. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the epidural steroid injection (62320) provided July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214), a lidocaine injection (J2001), and the removal of a nail plate (11730) provided on May 25, 2021, by an OON provider.    You asked the Plan to pay for an office visit, a lidocaine injection, and the removal of a nail plate. You say that the doctor informed the front desk secretary to obtain prior authorization, yet for some unknown reason, there was a misconception, and the patient was called in for treatment, prior to obtaining authorization. You also say that the doctor rendered medical services assuming that authorization was obtained. The Plan denied your request. The Plan says it was determined that the services were not urgent or emergent in nature. The Plan also says that an authorization was not obtained prior to the services being rendered and the provider is not participating with the member's plan.  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 an office visit (99214), a lidocaine injection (J2001), and the removal of a nail plate (11730) provided on May 25, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0482) provided on July 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you have performed the test at the request of the ordering physician and this test is deemed medically necessary for the treatment and management of this patient. The Plan denied your request. The Plan says the services were performed by a non-participating provider and were not authorized by the Plan. The Plan also says that the laboratory services were ordered by a non-participating provider.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on July 14, 2021, 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 pain management services provided on April 26, 2021. You asked the Plan to pay for the services provided. You say that the doctor is entitled to be reimbursed. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 72275 is epidurography, radiological supervision and interpretation. We find that code 72275 is not supported by the medical records. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service.   The CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. We find that code 99152 is not supported by the medical records. Specifically, the records do not document the service required the presence of an independent trained observer.   The CPT Code Manual definition of code 99153 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that code 99153 is a technical component only code. This code is not payable when billed for physician services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the ultrasound provided on July 26, 2021.  You asked the Plan to waive the cost share for the ultrasound. You say that the plan did not pay anything for the ultrasound. The Plan denied your request. The Plan says the copayment 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 $125 copay for Medicare-covered radiological diagnostic services.   You have been asked to pay $94.02 for the ultrasound. Because the amount is less than the $125 copay, you were charged the lesser amount. The ultrasound falls within the outpatient diagnostic tests 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 cost share for the ultrasound provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a septoplasty procedure (30520).  You asked the Plan to pre-approve a septoplasty. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been 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 a septoplasty. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the record does not indicate that the enrollee's nasal obstruction has proven unresponsive to a recent trial of conservative medical management.  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 septoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a septoplasty procedure (30520).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided from July 21, 2020, through September 8, 2020.  You asked the Plan to pay for inpatient hospital care. You say that the services rendered on dates of service July 21, 2020, to September 8, 2020, were pre-transplant services and should be processed at the submitted DRG of 001. The Plan states the provider is requesting additional payment for DRG 001 in the amount of $117,136.28. The Plan denied your request. The Plan says the provider has not submitted a corrected claim with additional/different diagnosis codes to support/substantiate their submission of DRG 001. The Plan states according to the diagnosis codes billed for the services provided, the derived DRG of 270 is correct and the claim processed correctly.  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 inpatient hospital care. Our physician reviewer found based on the provider's submitted diagnosis codes on the claim, the derived DRG for the services was 270. The provider has not submitted a corrected claim with additional/different diagnosis codes to support/substantiate their submission of DRG 001. According to the diagnosis codes billed for the services provided, the derived DRG of 270 is correct and the claim processed correctly. The review has determined that DRG 001 is not substantiated by the records provided. DRG 270 was appropriate based on the records provided.   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 care provided from July 21, 2020, through September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered on December 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99222 (initial hospital care) and 99497 (advance care
planning). Code 99497 is a column II code with a modifier indicator of 1 when billed with column I code
99222. Code 99497 was not billed with an appropriate modifier to allow for separate payment. Therefore, we
decided that the Plan does not have to pay for the advance care planning rendered on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental
pneumatic appliance (E0673) provided July 21, 2021.
You asked the Plan to pay for a pneumatic compression device and appliance. You say that these services are
not paid to you by the facility and payment for these items used should not be included with payment to the
facility as you bill charges separately for services provided under a DME license. The Plan denied your request.
The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis
during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during
and/or after 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. Therefore, we decided that
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance
(E0673) provided July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the flex-walk system (L5981).  

You asked the Plan to pre-approve the flex-walk system. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that a flex foot system is covered for an enrollee whose functional level is 3 or above.   

We looked at the file and Medicare rules. In this case, no documentation has been provided that indicates what the enrollee's functional level would be. Based on this information, we decided that Medicare rules for coverage of the flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve the flex-walk system (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on August 30, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says clinical records were not provided.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 the services provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by a participating provider on November 17, 2020.  

You asked the Plan to pay for dental services. You say that you have a $1,000 allowance. You say that this should be covered. The Plan denied your request. The Plan says the annual maximum amount has already been exhausted.  

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. The Plan covers a maximum allowance amount of $1,000 for dental services.  

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's annual maximum dental benefit is $1,000. Prior to the date of service in question, the annual maximum benefit amount of $1,000 was met. Therefore, we decided that the Plan does not have to pay for dental services provided by a participating provider on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on September
16, 2021.
You asked the Plan to pay for the gingival irrigation. You say that your gums were inflamed. You say that you
were in a lot of pain. You also say that you were given this office's information by a plan representative. The
Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.
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 gingival irrigation is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival
irrigation (D4921 x 2) provided on September 16, 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 enrollee's continuing acute care needs demonstrate medically-appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 is receiving appropriate care at the present acute care hospital. 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 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for after-cataract laser surgery provided by an in-network facility on September 22, 2021.  You asked the Plan to waive the copayment for the after-cataract laser surgery. You say that you were led to believe this service would be covered with no copayment. You say this service felt more like an office visit than a surgery. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.    The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.   You have been asked to pay a $250 copayment for the after-cataract laser surgery. The after-cataract laser surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the after-cataract laser surgery is considered a surgical procedure. 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 after-cataract laser surgery provided by an in-network facility on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the definitive drug testing provided on April 20, 2021.  You asked the Plan to pay for the drug testing. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says the records show that this lab sample was taken in the office setting. As such, the POS 11 should have been used.  The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.  We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on September 20, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says clinical records were not provided.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 the services provided on September 20, 2021.