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

We decided that the Plan has to pay for procedure codes 96366 and 96367 billed for date of service September 8, 2021.

You asked the Plan to pay for procedure codes 96366 and 96367. You say that you have provided records to support this billing. The Plan denied your request. The Plan says that the services are not supported by the medical records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

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 procedure codes 96366 and 96367. Our reviewer says that the medical records support the billing of these codes. Our reviewer found the enrollee is a 79-yr old female who received infusion services on September 8, 2021. You have reported Current Procedural Terminology (CPT) 96366 : intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure (1 Unit) and current Procedural Terminology (CPT) 96367 intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure (1 unit) for services provided. The doctor reviewed the submitted documentation and found that these billed codes are supported. The procedure report documents a start time of 09:40 and end time of 12:35. The time documented is 2 hours 55 minutes, so these billed services are supported.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 96366 and 96367 have been met. Therefore, we decided that the Plan has to pay for procedure codes 96366 and 96367 billed for date of service September 8, 2021.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Trastuzumab injection (Q5114), the Pegfilgrastim injections (Q5108), the Aprepitant injection (J0185), and the Pertuzumab injection (J9306) provided from July 21, 2021, through September 1, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs. Additionally, you must pay a 20% coinsurance for Medicare Part B non-chemotherapy drugs.
You have been asked to pay $1,973.65 ($595.96 + 533.43 + 533.43 + 310.83) for the Medicare Part B drugs provided. This amount is the less than the applicable coinsurance for these services. 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 coinsurance for the Trastuzumab injection (Q5114), the Pegfilgrastim injections (Q5108), the Aprepitant injection (J0185), and the Pertuzumab injection (J9306) provided from July 21, 2021, through September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam provided on October 8,
2021.
You asked the Plan to waive the copayment for a medical eye exam. You say that this was a routine eye exam
and should be subject to the $15 copayment. The Plan denied your request. The Plan says the copayment
applied was correct.
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 each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or
condition of the eye.
Medical records show that this visit was provided to treat a condition of the eye. You have been asked to pay a $40 copayment for a medical eye exam. A medical eye exam falls within the Vision Care 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 a medical eye exam provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections of a therapeutic or diagnostic substance (62320) provided o August 23, 2021.
You asked the Plan to pay for the injections. 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 include any medical records to verify the medical necessity of 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. We find that CPT code 62320 is not supported in the record. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for the injections of a therapeutic or diagnostic substance (62320) provided o August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospitalization.
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the requested inpatient psychiatric hospitalization is medically necessary. The Plan denied your request. The Plan says the requested inpatient psychiatric hospitalization does not meet criteria.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 18, 2022. You could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as you awaited placement. 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 psychiatric hospitalization have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advance care planning services (99497) provided on August 1, 2021. You asked the Plan to pay for code 99497. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 99497 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 99497 have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services (99497) provided on August 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on August 3, 2021.  

You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We looked at the file and Medicare rules. In this case, CPT code 93000 has a status indicator of M and the claim submitted denied for OCE 72 per Medicare payment guidelines. The Plan states they will accept a corrected claim for payment reconsideration for all claim lines. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on August 3, 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 appears to be somewhat unstable and requires only short-term additional acute care services that can be administered safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from May 7, 2021, to May 10, 2021.

You asked the Plan to pay for code S9328. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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.

We looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from May 7, 2021, to May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the panoramic x-ray provided on April 29, 2021.  

You asked the Plan to pay for the panoramic x-ray. You say that this bill is a financial hardship, and you feel this service should be covered. The Plan denied your request. The Plan says panoramic x-rays are not covered by your dental benefit.  

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. Specifically, the Plan's stated reason for denial of payment for the panoramic x-ray is that it is not a covered service. The Plan's contract clearly lists panoramic x-rays among those which are covered by your dental benefit. The contract does not state in clear terms how any limitations relate to any specific type of x-ray, nor was any evidence provided to show that the Plan's rules for coverage of this service have not been met. The Plan has not supplied sufficient information to support their denial of this claim. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on April 29, 2021.  

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve a continuation of SNF care. You say that the medical records provided support the need for continued SNF care. The Plan denied your request. The Plan says the enrollee is unable to make material gains with daily skilled therapy.

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 a continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the synovectomy (28086) and bunionectomy (28292) provided on June 3, 2021.  You asked the Plan to pay for the synovectomy (28086) and bunionectomy (28292). You say that procedure codes 28292 and 28086 are not included in another service and should be paid separately. The Plan denied your request. The Plan says CPT codes 28086 and 28292 are considered inclusive to CPT code 28750.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that modifier -59 is used to indicate a distinct procedural service.  In this case, the CPT Code Manual definition of code 28086 is synovectomy, tendon sheath, foot; flexor. The CPT Code Manual definition of code 28292 is correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method.  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 synovectomy (28086) and bunionectomy (28292). 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 modifier 59 as the procedures were performed on the same anatomical site.   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 synovectomy (28086) and bunionectomy (28292) have not been met. Therefore, we decided that the Plan does not have to pay for the synovectomy (28086) and bunionectomy (28292) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedure, by report (D9999) and periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided October 21, 2021.

You asked the Plan to pay for the unspecified adjunctive procedure and periodontal scaling and root planing. You say that you have used this dental office for years and the dentist said they haven't had issues with claims until recently. The Plan denied your request. The Plan says these services are not covered when rendered by a provider who has opted out of Medicare.

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 the unspecified adjunctive procedure and periodontal scaling and root planing when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the unspecified adjunctive procedure and periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pay for the unspecified adjunctive procedure, by report (D9999) and periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99283) and does not have to pay for the self-administered drugs (A9270) provided from October 21, 2021, to October 23, 2021.  You asked the Plan to waive the copayment for the emergency room visit and to pay for the self-administered drugs. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an emergency room visit and self-administered drugs provided on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied for the emergency room visit per your contract with the Plan and the self-administered drugs are not covered under your Medicare Part B benefit.  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 $90 copayment for Emergency care. The rules also say that Medicare Part B generally does not pay for self-administered drugs.  You have been asked to pay a $90 copayment for the emergency room visit and to pay for the self-administered drugs. The emergency room visit falls within the Emergency care 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. Additionally, the self-administered drugs provided to you during your outpatient stay are not among the type which are covered by Medicare Part B.  Based on this information, you are only responsible for the emergency room copayment and the self-administered drugs, totaling $102.49. You are not responsible for any charges beyond this amount for these services. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit (99283) and does not have to pay for the self-administered drugs (A9270) provided from  October 21, 2021, to October 23, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 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 were not billed correctly.
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 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on February 24, 2021.