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

 We decided that the Plan does not have to pay for the home infusion provided on March 5, 2021.  

You asked the Plan to pay for the home infusion. You say that the nursing visits notes are attached for review and the claim should be considered for payment. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes.  

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 supported in the medical record. Specifically, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, E2300, E2377, E2313, E2311, E1012).  

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested accessories are not medically necessary as she does have use of her hands and can operate and control the power options using the switches that are included in the basic wheelchair. Furthermore, the documentation does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder. She does not have a medical condition that requires elevated leg rests or the need for an expandable controller. The use of a Color Kit and seat elevator are not medical in nature therefore are 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, E2300, E2377, E2313, E2311, E1012).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from May 4, 2021, through May 9, 2021.

You asked the Plan to pay for inpatient care. The Plan denied your request. The Plan says the medical record supports that the enrollee was stable for transfer from 12:21 p.m. on May 6, 2021 per the Medicare standard for transferability namely that no material deterioration of his/her condition was likely, within reasonable medical probability, to result from or occur during transfer. Inpatient care at a non-Plan facility was not medically necessary to stabilize the enrollee.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 inpatient care at the non-Plan facility was not medically necessary. Our physician reviewer found that the enrollee was a 73-year-old male with a past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, Heart failure with preserved ejection fraction (HFpEF), hyperparathyroidism, and left great toe amputation who was brought in by ambulance to the non-Plan emergency department (ED) on May 4, 2021 with complaints of ataxia, confusion, and dysphagia. He did not have any focal weakness, facial asymmetry, or any speech difficulties. The enrollee was admitted with the diagnosis of a possible acute posterior circulation infarct. On May 6, 2021, per the Vascular Surgery progress note, no immediate surgical intervention was needed and at 12:20 p.m. the critical care physician's progress note stated that the enrollee was alert with no neuro deficits, and vital signs and labs were stable. Repeat computed tomography head (CTH) and magnetic resonance imaging (MRI) showed no acute findings and he was stable to transfer to telemetry. At 12:21 p.m. the enrollee was medically stable to safely transfer to a Plan facility. The review indicates that all inpatient care provided after 12:21 p.m. on May 6, 2021, through 2:59 p.m. on May 9, 2021 was not needed on an emergent basis at the non-Plan facility. The enrollee was hemodynamically and neurologically stable for ambulance transport with monitoring to a Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 

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 care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from May 4, 2021, through May 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. 

The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent annual wellness visits (G0439) provided on July 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for annual wellness visits. You say that there is a medical necessity pre-established with the enrollee and the facility for you to provide services to the patients needing care. You have enclosed the supporting records to prove the need for the services rendered. 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 subsequent annual wellness visits (G0439) provided on July 16, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 20, 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 this was billed with an inappropriate place of service for physician interpretation, per Medicare guidelines.

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 85060 is "Blood smear, peripheral, interpretation by physician with written report." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 80560 was billed with a POS (place of service) 22. CPT 85060 has a professional component/technical component (PCTC) Indicator of 8 which identifies the only time a payment can be made for the professional component of the service is for hospital inpatient, therefore CPT 80560 is not eligible for reimbursement consideration.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on December 23, 2021.  

You asked the Plan to pay for the services provided. You say that samples are sent from providers for testing. The Plan denied your request. The Plan says the billed codes 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 code. 

We looked at the file and the rules. The claim indicates a place of service as an independent laboratory. The records do not show that the specimen was obtained at an independent laboratory. 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 lab services provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on July 23, 2021.

You asked the Plan to pay for the Zoster (shingles) vaccine. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says coverage for this vaccine does not fall under your medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Zoster (shingles) vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on July 23, 2021.

Benefits for the Zoster (shingles) vaccine 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for the eye exams, computerized ophthalmic imaging, and the bevacizumab injections you received from March 3, 2021, to July 7, 2021.  

You asked the Plan to reduce the cost sharing for the eye exams, computerized ophthalmic imaging, and the bevacizumab injections. You say that you do not believe you should have two copayments for the same visit. The Plan denied your request. The Plan says you were charged this cost sharing 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 $25 copayment for eye exams, 15% coinsurance for diagnostic tests, and 20% coinsurance for Medicare Part B drugs.   

Records show that on each date of service, you had an eye exam, computerized ophthalmic imaging, and a bevacizumab injection. According to your contract, each of these services has a separate cost sharing amount associated with it. Your contract explicitly states that you pay a $25 copayment for each eye exam, 15% coinsurance for diagnostic tests (such as the computerized ophthalmic imaging you had), and 20% coinsurance for Medicare Part B drugs (such as bevacizumab injections.)  

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 reduce the cost sharing for the eye exams, computerized ophthalmic imaging, and the bevacizumab injections you received from March 3, 2021, to July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for anticoagulant management provided on July 19, 2021.  

You asked the Plan to waive the copayment for anticoagulant management. You say that you were told that you would not owe a copayment and you are not going into the office to receive this service. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for services received by a Level 1 specialist.   

You have been asked to pay the allowed amount of $10.23, which is less than the $35 copayment for anticoagulant management. Anticoagulant management falls within the physician/practitioner services, including doctor's office visits 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 anticoagulant management provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cast predominantly base metal pontic (D6211), porcelain fused to predominantly base metal pontic (D6241), full cast predominantly base metal retainer crown (D6791), and porcelain fused to predominantly base metal retainer crown (D6751) provided on July 15, 2021.  You asked the Plan to pay for the pontics and retainer crowns. You say that when you signed up for the enhanced vision and dental care, you did not read anything that stated what the bridge could be made of. You also say that the dental benefits did not state what kind of materials would be covered. The Plan denied your request. The Plan says prefabricated crowns used as final restorations on permanent teeth and prosthodontic services are benefit exclusions. The Plan also says that that composite resin (white) restorations on a posterior tooth and new or replacement of bridges are not covered services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cast predominantly base metal pontic (D6211), porcelain fused to predominantly base metal pontic (D6241), full cast predominantly base metal retainer crown (D6791), and porcelain fused to predominantly base metal retainer crown (D6751) provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor sensors (K0553) provided on February 12, 2021.

You asked the Plan to pay for Freestyle Libre sensors. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

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 Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor sensors (K0553) provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for fabrication and fitting of ocular conformer (CPT code V2628-LT)
provided to the enrollee on July 28, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid because this is a covered
Medicare service. The Plan denied your request. The Plan says that the DME service was billed with an
incorrect place of service.
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 is paying most of the claim with codes that have the same place of service as this denied CPT code.
Therefore, it is not appropriate that the Plan pays the other codes with the same place of service while denying
this code. Therefore, we decided that the Plan has to pay for fabrication and fitting of ocular conformer (CPT
code V2628-LT) provided to the enrollee on July 28, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99223) provided on August 11, 2021.  You asked the Plan to pay for the initial hospital care. You say that you believe this claim was submitted correctly. The Plan denied your request. The Plan says the claim was not billed in accordance with Medicare guidelines.  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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  We find that CPT code 99223 is not supported in the medical record. Specifically, the records provided note that initial hospital care coded as 99223 with a date of service of August 8, 2021, was previously paid by the Plan. These services were performed by the same provider as the August 11 claim. It does not appear appropriate for the Plan to pay a second time for services billed as initial inpatient hospital care. There is a more appropriate code that would reflect the services performed. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray (72190) provided on August 9, 2021.  

You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  

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 72190 is a column II code to column I code 73523. 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 an x-ray (72190) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99053) provided June 6, 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 separate 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 99053 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, the code billed has a status of "B" and payment is always bundled with another service. 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 (99053) provided June 6, 2021.