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

We decided that the Plan does not have to pay for the outpatient hospital services provided on July 24, 2020

You asked the Plan to pay for the outpatient hospital services. You say that this claim has been billed correctly. The Plan denied your request. The Plan says the claim in question has not been billed as required by Medicare coding regulations.

The Plan must follow Medicare rules. Medicare rules say that a device-intensive procedure that is reported without a device code results in an I/OCE edit of 92, meaning that the whole claim will be rejected and returned to the provider until the error is corrected. 

We looked at the file and Medicare rules. In this case, CPT code 28291, defined as hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant, without a corresponding device code. Without this device code, OCE Edit 92 is invoked. The required disposition for a claim with this edit is Return to Provider. This means the whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on July 24, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 28, 2021, through May 1, 2021.  You asked the Plan to pay for the acute inpatient level of care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the member was hemodynamically stable as of April 30, 2021.  The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting.   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 acute inpatient level of care. Our reviewer says that the member appeared to be hemodynamically stable and had a minor reaction to the vaccination the day prior but could have been treated with transfusion, fluids, and observation at a lower level of care. Our physician reviewer found it was not expected that this member would require hospital care that would likely cross 2 midnights.  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 acute inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided April 28, 2021, through May 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the administrative services for enteral nutrition services
(S9343).

You asked the Plan to pre-approve the administrative services for enteral nutrition services. You say that this is
medically necessary for your condition. The Plan denied your request. The Plan says this requested service is
not among those covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

We looked at the file and Medicare rules. In this case, administrative services related to home enteral nutrition
are not covered under the home health benefit. Based on this information, we decided that Medicare rules for
coverage of the administrative services for enteral nutrition services have not been met. Therefore, we decided
that the Plan does not have to pre-approve the administrative services for enteral nutrition services (S9343).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided on August 10, 2021.  You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that this service is a separately billable and payable code and should not be bundled or considered experimental. The Plan denied your request. The Plan says the clinical value and effectiveness of ultrasonic guidance for needle placement of trigger point injections for myofascial pain and spasm is considered experimental and investigational and have not been demonstrated in the peer-reviewed literature.  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 ultrasonic guidance for needle placement. Our reviewer says that the ultrasonic guidance for needle placement (76942) is not considered medically reasonable and necessary in this case. Our physician reviewer found ultrasonic guidance for needle placement of trigger point injections for myofascial pain and spasm is considered experimental and investigational and have not been demonstrated in the peer-reviewed literature. Our reviewer found that the standard of care for back trigger point injections is to not require ultrasound guidance but rather use tactile anatomical guidance. Our physician reviewer also found that without sufficient support made for this request, the ultrasonic guidance will be considered not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided on August 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF. You say that the enrollee could benefit greatly from the specialized and intensive care that would be provided in a SNF. You say that SNF care is essential to getting the enrollee up and walking again. You say that there is no way the enrollee can continue to recover and be safe at home in his current condition. The Plan denied your request.  The Plan says the records do not show that the enrollee's condition meets the requirements for coverage of SNF care. The Plan says that the enrollee's condition is stable, and he does not require daily skilled rehabilitation care or daily skilled nursing care.  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 SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does no require serves on an inpatient basis, only in a SNF setting. It would be appropriate to provide the services needed in a long-term care facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the technical component of a chest X-ray from a mobile radiology provider as well as the transportation and setup charges for services provided on April 25, 2021. 

 You asked the Plan to pay for the technical component and transportation/setup charges. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says this claim was denied per Medicare coding regulations.  

The Plan must follow Medicare rules. Medicare rules say that POS 31 is reported for enrollees in a Part A covered SNF stay. The technical component and transport/setup for mobile radiology services cannot be separately billed for a patient in a covered SNF stay.  

We looked at the file and Medicare rules. The POS reported in this case was 31. The billed codes are not separately payable with this POS code as these claims are not separately billed for an enrollee in a covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the technical component and transportation/setup charges have not been met. Therefore, we decided that the Plan does not have to pay for the technical component of a chest X-ray from a mobile radiology provider as well as the transportation and setup charges for services provided on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies (procedure code 99072) provided to the enrollee from August 30, 2021 to September 3, 2021.  

You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says this code has a status indicator of "B."  

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 99072 is "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other no facility service(s), when performed during a Public Health Emergency."

  We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the supplies (procedure code 99072) provided to the enrollee from August 30, 2021 to September 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on March 29, 2021.

You asked the Plan to waive the copayment for ambulance transportation. The Plan denied your request. The Plan says the copay applied to the claim is appropriate.

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 for Ambulance Services. 

You have been asked to pay a $250 copayment for ambulance transportation. Ambulance transportation falls within the Ambulance Services 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 ambulance transportation provided on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70470) provided September 20, 2021.  

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code has a bundled relationship with another code 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, we have confirmed that code 70470 is a column II code to column I code 70496. 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 radiology services (70470) provided September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and bitewings - four radiographic images (D0274) provided August 10, 2021.

You asked the Plan to pay for the periodic oral exam, dental cleaning, intraoral x-rays - first and additional images, and bitewing x-rays. You say that you have used this dentist in the past and were overdue for a dental cleaning due to the pandemic. The Plan denied your request. The Plan says out-of-network services are not covered under your 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. The Plan contract says that you are responsible for 100% of the cost of services provided out-of-network. 

We looked at the file and Medicare rules. 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 pay for these services. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning, intraoral x-rays - first and additional images, and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and bitewings - four radiographic images (D0274) provided August 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient consultation services (99285) provided on May 26, 2021.  

You asked the Plan to pay for the inpatient consultation services. You say that you would like reconsideration because the member was seen by multiple physicians with different specialties on the same date of service. The Plan denied your request. The Plan says this service is included in the global surgery period of another procedure that was billed on the same date of 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. 

 We find that CPT code 99285 is not supported in the record. Specifically, this service is included in the global surgery period of another procedure which was billed on the same date of service. Additionally, CPT code 99285 has a status indicator of I meaning that it is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation services (99285) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on  April 15, 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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules).  

You have been asked to pay a $40 copayment for the specialist visit provided. 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 office visit (99203) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 13, 2021.  

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  

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 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 out of network physician services provided to the enrollee on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a knee brace (L1851) and Lumbar-sacral orthosis (LSO) (L0650), provided on May 14, 2021.  You asked the Plan to pay for a knee brace and LSO. You say that the items were medically necessary. The Plan denied your request. The Plan says a phone call with the member indicated the DME company "contacted them out of the blue" and said they heard that the member had knee and back pain and they could provide the member with braces to help with this.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a knee brace and LSO have not been met. Therefore, we decided that the Plan does not have to pay for a knee brace (L1851) and Lumbar-sacral orthosis (LSO) (L0650), provided on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 15, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you do not owe $32,794.70 or $175. You say that you enclosed the receipt for the copayment but will only pay $24.40 when you get the bill. The Plan denied your request. The Plan says the self-administered drugs remain denied.

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. Please note, you were only charged the $175 copayment for outpatient surgery and $24.40 for the self-administeed drugs. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on September 15, 2021.

Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided from July 12, 2020, to July 17, 2020, and billed with DRG (diagnosis related group) 292.  You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the acute kidney injury 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.    In this case, you billed the inpatient services provided with diagnosis N17.9, acute kidney failure, unspecified, and DRG 292, heart failure and shock with complications or comorbidities. 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 care. Our reviewer says that the records do not support diagnosis N17.9 and DRG 292. Our physician reviewer found the enrollee was admitted with acute diastolic heart failure being treated with Lasix. Lasix was cut back and changed to oral due to acute kidney injury. The creatinine at admission was 1.15 and increased to 1.44 showing a significant increase. The creatinine trended down to 1.27 at the time of discharge.   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 care provided from July 12, 2020, to July 17, 2020, and billed with DRG (diagnosis related group) 292.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from April 4, 2020, to April 8, 2020, and billed with DRG (diagnosis related group) 871.

You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says that the sepsis diagnosis is not supported.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan indicated that records were submitted by the provider and references records in their decision, but the Plan did not include any medical records in the submitted case file. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for inpatient care provided from April 4, 2020, to April 8, 2020, and billed with DRG (diagnosis related group) 871. 

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.