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

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 23, 2020, through November 30, 2020 and billed with Patient Driven Payment Model score KDFF1 x 8 days.
You asked the Plan to pay for the SNF services billed with PDPM score KDFF1 x 8 days. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the PDPM score billed
The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM score KDFF1 x 8 days have not been met. Specifically, the documentation submitted is incomplete. Section GG Self-Care and Mobility items and Section I0020B, primary medical ICD Code, have not been coded. We are unable to validate the PDPM code billed without this information. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 23, 2020, through November 30, 2020 and billed with Patient Driven Payment Model score KDFF1 x 8 days.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy (29821) provided on September 14, 2021.
You asked the Plan to pay for the shoulder arthroscopy (29821). You say that the claim should be re-evaluated for payment with the supporting documentation as this has been denied in error. The Plan denied your request. The Plan says code 29821 is considered inclusive to CPT code 29827-LT and consequently be denied.
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 29821 is arthroscopy, shoulder, surgical; synovectomy, complete. 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 shoulder arthroscopy (29821). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not support billing the rotator cuff separately. 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 shoulder arthroscopy (29821) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy (29821) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 7, 2021.
You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are not separately
reportable.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the lab services provided on July 7, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0075 provided on August 11, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 R0075 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen.
We find that CPT code R0075 is not supported in the medical record. Specifically, the documentation shows
that the enrollee was in a hospital facility setting for this date of service. This means that this place of service
was inappropriate for this procedure code. Based on this information, we decided that Medicare rules for
coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not
been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray
equipment and personnel to home or nursing home coded R0075 provided on August 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires rendered on July 2, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. We looked at the file and Medicare rules. Billed procedure code A4557 (lead wires, per pair) has a status indicator of P and has no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the lead wires rendered on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extractions (D7140) or pay more for the maxillary immediate denture (D5130) provided on August 16, 2021, and September 14, 2021.
You asked the Plan to pay for the simple extractions and to pay more for the maxillary immediate denture. You say that both you and your wife contacted the Plan and were told that all would be covered by two different representatives. You also say that your dentist contacted the Plan and was advised there would be no charge. The Plan denied your request. The Plan says the annual limit allowed by your dental plan for the 2021 benefit year was paid. The Plan also says that you, your wife, and the provider were given no misinformation during the calls with the Plan.
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 Plan offers up to a $1,000 allowance every year for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing the claim for the August 16, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the simple extractions (D7140) or pay more for the maxillary immediate denture (D5130) provided on August 16, 2021, and September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) for trigger-point injections provided on March 12, 2021.
You asked the Plan to pay for ultrasonic guidance. You say that the procedure at issue should not be considered experimental. The Plan denied your request. The Plan says rules for payment have not been met because the services at issue are experimental/investigational.
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 ultrasonic guidance. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer
found that ultrasound guidance for trigger point injections is considered experimental/investigational. There is no clinical practice guideline that supports its use in this situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasonic guidance have not been met. Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) for trigger-point injections provided on March 12, 2021
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the Magnetic Resonance Imaging (MRI) of the abdomen (74181).
You asked the Plan to pre-approve the MRI of the abdomen. You say that you would like reconsideration
because the requested MRI is medically necessary. The Plan denied your request. The Plan says that the
member does not meet Medicare criteria for coverage of the requested MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
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 MRI of the abdomen. Our reviewer
says that considering the member is a poor historian and imaging may elucidate the cause of the elevated liver
function tests and to determine if endoscopic retrograde cholangiopancreatography or cholecystectomy alone
would be most appropriate moving forward for the member. This would be the least invasive order of testing.
Our physician reviewer found this request for MRI/Magnetic resonance cholangiopancreatography is
reasonable and medically necessary in the case of this member.
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 MRI of the abdomen have been met. Therefore, we decided that the Plan has
to pre-approve the Magnetic Resonance Imaging (MRI) of the abdomen (74181).
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 pay for chiropractic manipulation to extra-spinal regions (98943) electrical stimulation (G0283) mechanical traction (97012) provided August 25, 2021.
You asked the Plan to pay for the chiropractic service. You say that please see attached medical notes for medical necessity. The Plan denied your request. The Plan says this service is not covered when billed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation to extra-spinal regions (98943) electrical stimulation (G0283) mechanical traction (97012) provided August 25, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (86003) provided March 5, 2021.
You asked the Plan to pay for the lab services. You say that the tests were medically necessary. The Plan denied your request. The Plan says the records provided do not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Insufficient medical records were provided to support the billed lab services. Records were limited ot lab results with no clinical documentation. The plan requested additional records and none were received. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (86003) provided March 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on August 25, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 31 for a skilled nursing facility but the records show the enrollee was under hospital status. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 24, 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 the services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted a claim for procedure code 99202 (office visit). Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the sesamoidectomy (28315) provided on May 25, 2021.
You asked the Plan to pay for the sesamoidectomy (28315). You say that you disagree with this denial and
have highlighted the operative report to show this was a separate procedure. The Plan denied your request. The
Plan says CPT code 28315 is included in CPT code 28292 and cannot be separately reimbursed.
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 28315 is sesamoidectomy, first toe (separate procedure).
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 sesamoidectomy (28315). Our reviewer says that the
documentation was reviewed and does not meet the criteria for coverage. Our reviewer found that the
procedure report describes a sesamoidectomy and bunionectomy in the same anatomical area. CPT 28292
includes a sesamoidectomy and modifier 59 would only be reported when a procedure is reported in a different
anatomical area.
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 sesamoidectomy (28315) have not been met. Therefore, we decided that the
Plan does not have to pay for the sesamoidectomy (28315) provided on May 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on September 25, 2019, through September 30, 2019 and billed with Patient Driven Payment Model (PDPM) score RMC x 6.
You asked the Plan to pay for the SNF services billed with PDPM RMCx6. You say that you would like reconsideration because the documentation supports the PDPM score billed. The Plan denied your request. The Plan says the documentation does not support the coding of the ADL's on the admission assessment.
The Plan follows Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). 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 SNF services billed with PDPM RMCx6. Our reviewer says that the Activities of Daily Living (ADL) indicator represented at the level "C" in the billed RUG score RMC as reported by the provider, but the documentation only supported a level "B". Our physician reviewer found a level "C" ADL assistance level indicates the most extensive amount of staff resources was used by the member during the lookback period of 9/25-9/30/2019, but the documentation indicates a lesser amount of staff resources was used by the member to complete the ADL tasks. the provider billed extensive level of assistance of 2 staff was provided, where the documentation indicates moderate amount of staff assistance was provided, thus changing thebilled RUG score from RMC x 6 days to RMB x 6 days, as the documentation supported an ADL score of 8 and the requirements for billing a level "C" is an ADL score of 11 or greater. The review has determined that the admission assessment did not show assist of 2 staff for at least 1 episode on bed mobility, transferring, and toileting 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 SNF services billed with PDPM RMCx6 have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on September 25, 2019, through September 30, 2019 and billed with Patient Driven Payment Model (PDPM) score RMC x 6.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services, more than 30 minutes (99239) provided February 18, 2021.
You asked the Plan to pay for the hospital services. You say that enclosed is the requested medical records and you would appreciate reconsideration of your claim for payment. The Plan denied your request. The Plan says the records do not support the billed service.
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 99239 is the hospital discharge day management services, more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary do not support hospital discharge day management of more than 30 minutes was performed. The Plan made multiple attempts to the provider for additional information. Based on this information, we decided that
Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services, more than 30 minutes (99239) provided February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) provided on October 12, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $40 copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that the provider is no longer contracted with the Plan, and you were notified that if you continued to see this provider, you would be assessed a specialist copayment. 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 a specialist office visit (99203) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on October 4, 2021.
You asked the Plan to pay for prophylaxis. You say that this was your first cleaning of the year. You say that this should be covered. The Plan denied your request. The Plan says the benefit limit for D1110 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 prophylaxis twice per calendar year. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of prophylaxis have already been met. Evidence was provided to show that D1110 was provided on
March 1, 2021, and June 2, 2021. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on May 14, 2021.
You asked the Plan to pay for the hearing aids. You say that the provider said they participated with your Plan's hearing aid vendor. You say that you have in and out-of-network coverage and don't understand why these are not covered. The Plan denied your request. The Plan says to receive the hearing aid benefits you should have contacted the Plan's hearing aid vendor to set an approved appointment.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when the purchase is organized through the Plan's hearing aid vendor. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, you did not contact the Plan's hearing aid vendor to purchase the hearing aids. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on May 14, 2021.
Your complaint about being taken advantage of by the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.