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

 We decided that the Plan does not have to pay for the laparoscopy (CPT code 49650-AS) provided to the enrollee on June 7, 2021.  You asked the Plan to pay for the laparoscopy. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met.  Medicare doesn't pay for assistants at surgery services furnished in a teaching hospital, which has a training program related to the required medical specialty, and has a qualified resident available, except if the physician certifies that a qualified resident was not available, or if the primary physician has a policy of never involving residents in surgery, or if exceptional medical circumstances exist. Therefore, we decided that the Plan does not have to pay for the laparoscopy (CPT code 49650-AS) provided to the enrollee on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for hematology comprehensive genomic profile (CPT code 81455) provided to the enrollee on July 15, 2020.  You asked the Plan to pay for the testing. You say that the service was denied as experimental in error. The Plan denied your request. The Plan says the Medicare rules have not been met.  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 does not cover testing panels. The information submitted with the appeal are for testing panels. The performance of multiple molecular tests regardless of whether the requisition lists the tests as a panel or individually and completed on a single sample is considered to be a panel of tests and should be billed under a single CPT code to prevent stacking of codes per CMS guidance. The proprietary lab is requesting coverage of the comprehensive panel by stacking codes. Medicare rules which say that providers must report services correctly. The providers must report services with the appropriate CPT code. Also, per LCA A56199 for Billing and Coding: Molecular Pathology Procedures, CPT code 81455 is Group 3 which is a Tier 1 non-covered codes for genetic testing procedures. The testing submitted under this CPT code is unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for hematology comprehensive genomic profile (CPT code 81455) provided to the enrollee on July 15, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrocardiographic (EKG or ECG) monitoring (Holter or Real-Time Monitoring), provided on April 20, 2021.  You asked the Plan to pay for electrocardiographic (EKG or ECG) monitoring. The Plan denied your request. The Plan says the supporting documentation found the service is considered to be not reasonable and necessary for all patients with symptoms such as palpitations, dizziness, or weakness.  The Plan must follow Medicare rules. Medicare rules say that Real-Time, Outpatient Cardiac Telemetry is considered to be not reasonable and necessary for all patients with symptoms such as palpitations, dizziness, or weakness. To be considered medically necessary, the ordering physician must document that he/she has concluded that the patient's symptoms are severe enough to warrant further investigation, an underlying dysrhythmia is a likely cause of their symptoms, and that the identification of the suspected dysrhythmia can only be determined through the use of this service.  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 electrocardiographic (EKG or ECG) monitoring. Our reviewer says that the electrocardiographic (EKG or ECG) monitoring was not medically necessary. Our physician reviewer found that there is no documentation provided to support that a significant cardiac arrhythmia was a likely cause of the enrollee's symptoms, or that the diagnosis of a significant cardiac arrhythmia as the cause of her symptoms could only be established with an MCOT monitor with real-time telemetry. There is no supportive evidence that the ordering practitioner documented that other testing and ECG monitoring had been negative.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrocardiographic (EKG or ECG) monitoring have not been met. Therefore, we decided that the Plan does not have to pay for electrocardiographic (EKG or ECG) monitoring  (Holter or Real-Time Monitoring), provided on April 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a nasal endoscopy (31276) provided on April 20, 2021.  You asked the Plan to pay for a nasal endoscopy. You say that this was authorized. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.  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 31276 is nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed.  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 a nasal endoscopy. Our reviewer says that this code is not supported. Our reviewer found the operative report does not include documentation of frontal sinus exploration, including removal of tissue from frontal sinus.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a nasal endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a nasal endoscopy (31276) provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.  You asked the Plan to pre-approve the heavy duty extra wide hospital bed. You say that you require the wide bed due to other ailments, even though you are not over 350 pounds. The Plan denied your request. The Plan says you do not meet coverage criteria.  The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the enrollee meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. You do not meet coverage criteria because you are not more than 350 pounds. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for skilled nursing facility (SNF) services you received from January 18, 2021, to January 22, 2021.  You asked the Plan to waive the deductible for the SNF services. You say that you were admitted to the SNF due to COVID-19, so the deductible should be waived. The Plan denied your request. The Plan says you were assessed this deductible appropriately.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $450 deductible which applies to skilled nursing facility services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 deductible which applies to skilled nursing facility services. This cost sharing is a contractual obligation that had not been met at the time the SNF services were received on January 18, 2021, to January 22, 2021. In addition, the Plan's website states that the Plan does cover COVID-19 treatment, but copayments, deductibles, and coinsurance will apply according to your contract. Therefore, we decided that the Plan does not have to waive the deductible for skilled nursing facility (SNF) services you received from January 18, 2021, to January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided in an oncologist's office on March 23, 2021.  You asked the Plan to waive the coinsurance for the radiation therapy. You say that you cannot afford this bill. The Plan denied your request. The Plan says you were charged this coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for radiation therapy.   The enrollee has been asked to pay 20% coinsurance for the radiation therapy. 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 coinsurance for radiation therapy services provided in an oncologist's office on March 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport provided on October 2, 2020.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel you should not be held responsible for the payment for this service since you called the ambulance. The Plan denied your request. The Plan says you are covered for Ambulance services however, the Plan only covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. The Plan also says that there was no transportation to the hospital for this visit.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on October 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for services you received with an out-of-network physician's assistant on October 28, 2020.  You asked the Plan to waive the deductible for the out-of-network physician's assistant services. You say that you have been seeing your doctor as your primary care provider for 18 years.  You said that this claim should be paid as in-network. The Plan denied your request. The Plan says this physician's assistant and the referring doctor are both out-of-network providers with your plan.  As a result, you were assessed this deductible correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to out-of-network medical services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to out-of-network medical services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network physician's assistant services were received on October 28, 2020. Therefore, we decided that the Plan does not have to waive the deductible for services you received with an out-of-network physician's assistant on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint denervation (64633, 64634).  You asked the Plan to pre-approve facet joint denervation. You say that the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.  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 facet joint denervation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record sent by your provider indicates that the last thoracic medial branch block provided less than 80% improvement.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint denervation have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint denervation (64633, 64634).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hematology lab services provided on May 20, 2021.  You asked the Plan to pay for the testing services. You say that the services should not be considered as bundled. The Plan denied your request. The Plan says the use of the modifier is not supported.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  We looked at the file and the rules. We find that codes 81263 and G0452 were billed with the -59 modifier. The medical records provided do not show that the services at issue were distinct procedural services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the hematology lab services provided on May 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the enrollee on April 1, 2021.  You asked the Plan to pay for the abdominal ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the abdominal ultrasound have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76705 and 93976. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the enrollee on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided from November 22, 2020, to November 23, 2020, and billed with DRG (diagnosis related group) 871.  You asked the Plan to pay for inpatient care. You say that the billed DRG was correct. The Plan denied your request. The Plan says the records do not support the sepsis 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 DRG 871, septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major 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 billed DRG is not supported. Our physician reviewer found while the provider documented "sepsis, due to early pneumonia or acute bronchitis," the medical records' support was incomplete regarding sepsis. There was no clinical or laboratory evidence of sepsis.   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 November 22, 2020, to November 23, 2020, and billed with DRG (diagnosis related group) 871.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you had on April 18, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that this transport was necessary because you had a head and neck injury. The Plan denied your request. The Plan says these services weren't denied, but rather your bill represents your cost sharing.  The Plan says that you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($226.97) is less than your copayment obligation, you are responsible for the full allowed 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 $250 copayment per trip for ambulance services.   You have been asked to pay a $250 copayment per trip for the ambulance 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 copayment for ambulance services you had on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic procedure (D0999) provided on August 11, 2020.  You asked the Plan to pay for the diagnostic procedure. You say that the provider informed you that this service is covered by Medicare. You also say that this service was to permit medical diagnosis of inflammatory conditions of the jaw. The Plan denied your request. The Plan says this service is not covered by Medicare. The Plan also says that you had no supplemental benefit plan for the provided dental service.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the diagnostic procedure (D0999) provided on August 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (90834) provided on May 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied your request. The Plan says prior authorization is required for non-emergent services obtained by an out-of-network provider.  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 psychotherapy (90834) provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided on April 5, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the services were not billed as required by coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code 99153 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; each additional 15 minutes intraservice time. We find that CPT code 99153 is a technical component only code. This code is covered only as diagnostic tests and therefore do not have a related professional code.  The CPT Code Manual definition of code is Transcatheter therapy, arterial infusion for thrombolysis other than coronary or intracranial, any method, including radiological supervision and interpretation, initial treatment day. We find that CPT code 37211 was billed with code 37184. CPT code 37211 may be eligible for payment when billed with this code pair. However, the claim provided does not indicate that the code at issue was not billed with a modifier suitable for payment. 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 medical services provided on April 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the non-invasive extremity study you had on June 24, 2021.  You asked the Plan to waive the copayment for the non-invasive extremity study. You say that you have never been charged for this test in the past. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($76.13) is less than your copayment obligation, you are responsible for the full allowed 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 $150 copayment for radiological diagnostic services.   You have been asked to pay a $150 copayment for the non-invasive extremity study. The non-invasive extremity study falls within the radiological diagnostic services benefit category. This copayment applies regardless of what you may have paid in the past. 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 non-invasive extremity study you had on June 24, 2021.