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

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a planned lumbar L4-5 laminectomy. You are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopic enterectomy (44202) provided on June 17, 2020.

You asked the Plan to pay for a laparoscopic enterectomy. You say that this is supported in the records. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.

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 44202 is laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis.

We find that CPT code 44202 is not supported in the medical record. Specifically, the records indicate that an open procedure was performed. Based on this information, we decided that Medicare rules for coverage of a laparoscopic enterectomy have not been met. Therefore, we decided that the Plan does not have to pay for a laparoscopic enterectomy (44202) provided on June 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied for the Esophagogastroduodenoscopy, transoral; with biopsy (43239) provided on April 7, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible 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 $1,000 yearly deductible. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. 

You have been asked to pay a $236.14 deductible for the endoscopy provided as you have not previously met the yearly deductible. This is the Plan's allowed amount for this service. 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 deductible applied for the Esophagogastroduodenoscopy, transoral; with biopsy (43239) provided on
April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on June 8, 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 procedure codes 64615 and J0585 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 64615 is chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine). The definition of code J0585 is injection, onabotulinumtoxina, 1 unit. We find that CPT codes 64615 and J0585 are not supported in the medical record. Specifically, there is no documentation of chemodenervation of the muscles to support code 64615. There is no documentation of an
onabotulinumtoxinA injection to support code J0585. 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 injection services rendered on June 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the shock wave crushing of kidney stones provided February 25, 2021.
You asked the Plan to waive the copayment for the shock wave crushing of kidney stones. You say that you have received this bill several times and should not be charged because the service was not performed. The
Plan denied your request. The Plan says the claim has reprocessed, and you are now being charged the correct copayment.
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 $350 copayment for same-day outpatient surgery in a freestanding Ambulatory Surgical Center. You have been asked to pay a total cost share of $175 for the shock wave crushing of kidney stones. This service falls within the same-day outpatient surgery in a freestanding Ambulatory Surgical Center benefit category. The documentation included clarifies that this procedure was not performed and was cancelled prior to anesthesia. Therefore, based on Medicare you are only subject to one-half the required copayment. One-half of the required copayment of $350 is $175. 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 shock wave crushing of kidney stones provided February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular nerve stimulator (a device used to control pain) and associated procedure (CPT code(s): L2679 and 64555), for the enrollee.
You asked the Plan to pre-approve the service. You say that this procedure is cleared by the FDA and is covered by Medicare, Tricare, and commercial insurance. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's health problem. The Plan states CPT code 64555 is described as: Percutaneous implantation of Neurostimulator electrode array; peripheral nerve (excludes sacral nerve) and that the CPT-code 64555, does not describe the procedure of auricular acupuncture stimulation. The Plan states that it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system; the health plan feels that the denial of the Auricular PNS device was appropriate given the clinical scenario and the guidance presented.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that this is effective therapy. Therefore, the request is deemed not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve auricular nerve stimulator (a device used to control pain) and associated procedure (CPT code(s): L2679 and 64555), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series (D0210), provided on April 22, 2021.

You asked the Plan to pay for the routine dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exhausted your Plan benefit for these services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, documentation submitted shows you received the requested services on September 16, 2019. This means you are not eligible to receive these services again until September 16, 2022. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series (D0210), provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-ray provided on April 12, 2021 and the immediate upper and lower denture, unspecified prosthodontic procedure and surgical extractions provided on April 29, 2021.

You asked the Plan to pay for the comprehensive oral evaluation, intraoral x-ray, immediate upper and lower denture, unspecified prosthodontic procedure and surgical extractions.. You say that you did not like their protocols and there was no privacy, so you went to another dentist for x-rays. You say that you feel much calmer with the new dentist, and they have better protocols. The Plan denied your request. The Plan says you have exceeded the limitations for the comprehensive oral evaluation and intraoral x-ray. The Plan also says that the immediate upper and lower denture, unspecified prosthodontic procedure and surgical extractions are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one comprehensive oral evaluation every 36 months and one intraoral complete series x-ray every 60 months. The Plan paid for the comprehensive oral evaluation and intraoral x-ray provided on September 2, 2020, which exhausted your benefit. The immediate upper and lower denture, unspecified prosthodontic procedure and surgical extractions are not covered benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-ray provided on April 12, 2021 and the immediate upper and lower denture, unspecified prosthodontic procedure and surgical extractions provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to your deductible for an annual wellness visit and services stemming from that visit on May 3, 2021.

You asked the Plan to waive this cost share. You say that these services should be no charge for an annual visit. The Plan denied your request. The Plan they received medical records from the providers office. The records state you were seen for an office visit for vomiting, in addition to your annual wellness exam. The medical records also show that you received lab work and were administered a pneumococcal vaccine. Per your 2021 Evidence of Coverage (EOC), Chapter 4, Page 52, under Annual wellness visit, it states that until you meet your yearly deductible, you pay 100% of the Medicare-approved amount or network contracted rate.

The Plan contract also stated under Immunizations, that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate. The Plan contract further states on page 70, under Outpatient diagnostic tests and therapeutic services and supplies, that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate, and Page 75, of the contract, under Physician/Practitioner services, including doctor's office visits, it states that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate. At the time of service, the yearly deductible had not been satisfied. Therefore, these charges were applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is deductible which applies to services rendered in 2021. The Plan has followed Medicare rules by clearly disclosing in the contract that there is deductible which applies to each of the services provided and in particular to the annual wellness visit. 2021. This cost sharing is a contractual obligation that had not been met at the time of service. Therefore, we decided that the Plan does not have to waive the cost share applied to your deductible for an annual wellness visit and services stemming from that visit on May 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmic ultrasound (76514) provided on February 4, 2021.

You asked the Plan to waive the copayment for an ophthalmic ultrasound. You say that you have already paid your copayment to see a specialist and the ophthalmic ultrasound was performed in the same visit. The Plan denied your request. The Plan says the correct copayment 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 a $10 copayment for each Medicare-covered advanced radiology service. The Plan contract also says that, if advanced radiology services are performed in the provider's office during an office visit, the appropriate office visit copayment and advanced radiology service copayment will apply. 

In this case, an ophthalmic ultrasound was provided in the provider's office during an office visit. You have been asked to pay a $10 copayment for an ophthalmic ultrasound. An ophthalmic ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for an ophthalmic ultrasound (76514) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) and specialty physician services rendered on April 13, 2021 to April 22, 2021.

You asked the Plan to waive the copayments for these services. You say that you disagree with the copayments. The Plan denied your request. The Plan says the copayments were 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 $120 copayment for each emergency room visit in the US and a $10 copayment for specialty care physician services. You can find this information on page 85 of the 2021 EOC.

Review of the file shows that you received ER services from April 13, 2021 to April 14, 2021. You have been asked to pay a $120 copayment for these services. These services fall within the emergency room visit in the US benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received specialty physician services on April 22, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the specialty care physician services benefit category. This means that you have been asked to pay the correct amount for these services based on the contract with the Plan.

The total amount you have been asked to pay for these services is $130. 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 copayments for the emergency room (ER) and specialty physician services rendered on April 13, 2021 to April 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 11, 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 procedure code 99285 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity.
We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not support the Level 5 intensity of services. 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 emergency room (ER) services rendered on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673), provided on October 19, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the device was used in a hospital setting.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a pneumatic compression device was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673), provided on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs may be met in a long-term care setting, with part-time skilled services, if approved by the health plan.

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 admission is not medically reasonable or necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy. You appear to have reached a new baseline of function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care, such as home, assisting living, or long-term 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 inpatient skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 12, 2020.

You asked the Plan to pay for drug testing. You say that physicians send specimens to you for testing and you do not have access to physician notes and reports. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim.

Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (code 93978-26) provided on June 4, 2021.

You asked the Plan to pay for duplex scan. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 93978 is a column 2 code with a modifier indicator of 0 when billed with 93976 which means there are no circumstances in which both procedures should be paid for the same beneficiary on the same day by the same provider.

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 duplex scan has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (code 93978-26) provided on June 4, 2021.