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

We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee on February 1, 2020.
You asked the Plan to pay for the services. You say that there is ample evidence including in the documentation packet to support the coding of section GG on the 5 day assessment dated 2/4/20. The Plan denied your request. The Plan says that there are inconsistencies between the documentation in the medical records and the coding of the 5 day Minimum Data Set (MDS) assessment.
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 did not make any specific argument as to which functional abilities were felt to be incorrectly scored. The plan has not provided enough evidence to claim that the assessment coding was not done correctly. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee on February 1, 2020.
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 the new patient domiciliary or rest home visit (99326) provided on July 6, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the domiciliary or rest home visit. You say that your physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the new patient domiciliary or rest home visit (99326) provided on July 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on September 21, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the plan did not receive a primary carrier's Explanation of Benefits in initial correspondence nor even after making outreaches.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has reached out multiple times to the primary carrier for the Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on September 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99601) provided June 15, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for payment.  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 99601 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "I" and is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99601) provided June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the debridement services provided from June 1, 2021, to June 29, 2021.  

You asked the Plan to waive the cost shares for the services provided. The Plan denied your request. The Plan says the enrollee was assessed the correct copays.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $370 copay for outpatient surgery.   

The file shows that the enrollee received debridement services on June 1, 15, and 29, 2021. The enrollee has been asked to pay $317.87 for each date of service. Because the amount is less than the $370 copay, the enrollee has been asked to pay the lesser amount.  

The services fall within the outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost shares for the debridement services provided from June 1, 2021, to June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99215) provided on August 26, 2021.  

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.  

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services (99215) provided on August 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 8 home health physical therapy visits, 8 home health occupational therapy visits, and 4 home health skilled nursing visits.  You asked the Plan to pre-approve 8 home health physical therapy visits, 8 home health occupational therapy visits, and 4 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 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 8 home health physical therapy visits, 8 home health occupational therapy visits, and 4 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested additional skilled physical and occupational therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Records do not document any acute or unstable medical conditions or changes in functional status which would necessitate any further skilled physical therapy or occupational therapy visits beyond what have already been approved. Further utilization of the home exercise program and caregivers in the home appears appropriate at this point. No medical notes from the enrollee's treating physician are provided documenting an order or need for additional skilled therapy 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 8 home health physical therapy visits, 8 home health occupational therapy visits, and 4 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health physical therapy visits, 8 home health occupational therapy visits, and 4 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) performed on August 10, 2021.  You asked the Plan to waive the copayment for the EKG. You say that you have had this test done before with no charge. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each diagnostic test or procedure performed in an outpatient hospital, including electrocardiograms.   You have been asked to pay $50.84, which is less than the $90 copayment for the EKG. The EKG 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 electrocardiogram (EKG) performed on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the duplex scan interpretation provided on May 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON radiology services. You say that this was medically necessary testing and should be paid. The Plan denied your request. The Plan says these services were ordered by an OON provider, and no authorization was requested for these services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the duplex scan interpretation provided on May 13, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on Mach 18, 2020.    

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  

The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on Mach 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided October 29, 2020.  You asked the Plan to provide additional payment for the immediate upper and lower dentures. You say that you were dissatisfied with the care received and would like the charges covered. The Plan denied your request. The Plan says an exception was made to cover the services with 50% coinsurance. Additionally, you are responsible for the cost above the allowed amount since services were provided out-of-network.  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 immediate upper and lower dentures with 50% coinsurance when provided in-network.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing they have made an exception to cover the services and have paid 50% of the allowed amount according to their in-network benefits. You are responsible for any remaining costs billed by the provider over the allowed amount. Therefore, we decided that the Plan does not have to provide additional payment for the immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided October 29, 2020.   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve wound care to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion services provided on June 7, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is invalid for usage with Medicare.  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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). We find that CPT code 99601 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on June 2, 2021.  

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed service cannot be verified.  

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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.  

We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that the sedation services required the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye examination, retinal photograph provided on  August 5, 2021.  You asked the Plan to pay for the eye examination. The Plan denied your request. The Plan says a retinal photograph is not a covered vision benefit.  Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that a retinal photograph is not covered under the routine eye exam benefit. Therefore, we decided that the Plan does not have to pay for an eye examination, retinal photograph provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from July 1, 2021 to July 28, 2021.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment is not allowed because the place of treatment code is inconsistent with the procedure code.  

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 H0019 is "Behavioral health; long-term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem."  

We find that procedure code H0019 is not supported in the medical record. Specifically, the place of treatment code and the procedure code do not match. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from July 1, 2021 to July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on August 16, 2021.  You asked the Plan to waive the copayment for these services. You say that the services are injections and have nothing to do with a treatment room. The Plan denied your request. The Plan says the copayment was 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 $250 copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center.   Review of the file shows that you received trigger point injections billed with code 20552 on August 16, 2021. These services are classified as a surgical procedure by the American Medical Association (AMA). Per the contract with the Plan, there is a $250 copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $234.56. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $234.56 for these services.  Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 25, 2021.  You asked the Plan to pay for the limited oral exam. You say that you don't understand why this visit would not be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam once per plan year.  We looked at the file and Medicare rules. In this case the Plan provided documentation showing that a limited exam was previously covered on April 15, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 25, 2021.