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

 We decided that the Plan does not have to pay for the laparoscopy (49652) provided on May 28, 2021.  You asked the Plan to pay for the laparascopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says taxonomy 163WR0006X is not found on the crosswalk for types of providers and suppliers who are eligible to apply for enrollment in the Medicare program.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 49652 is not supported in the record. Specifically, the taxonomy code billed on the claim is not included in the Medicare Provider and Supplier Taxonomy Crosswalk. This Crosswalk is a list of the type of providers and suppliers with the proper taxonomy code eligible for Medicare programs. Based on this information, we decided that Medicare rules for coverage of the laparascopy have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy (49652) provided on May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on July 14, 2021 to July 20, 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 are not covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on July 14, 2021 to July 20, 2021.   Benefits for these services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (15004) provided on May 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 15004 is "Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children." 

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 use of code 15004 is not supported by the records provided. Our reviewer found that surgical preparation codes, CPT codes 15002-15005 are to be used for the initial traumatic would preparation. In this case, the operative report does not support CPT code 15004 as an independent procedure, and therefore this code would not be covered. 

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 the services (15004) provided on May 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the Velcade injection wastage (J9401) provided on July 17, 2020.

You asked the Plan to pay for the Valcade injection wastage. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical record does not include medication wastage documentation for Bortezomib.

The Plan must follow Medicare rules. Medicare rules say that providers must record the discarded amounts of drugs and biologicals in the patient's medical record. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Valcade injection wastage have not been met. Specifically, the medical record submitted does not include documentation of the discarded amounts of Bortezomib (Velcade). Therefore, we decided that the Plan does not have to pay for the Velcade injection wastage (J9401) provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four simple extractions (D7140 x4) provided from June 22, 2021, to August 23, 2021.

You asked the Plan to pay for the extractions. You say that you were not aware that extractions were not a covered service under your dental plan. The Plan denied your request. The Plan says these services are not covered.

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. The Plan has also confirmed that you were not enrolled in an optional supplemental dental plan on these dates of service. Therefore, we decided that the Plan does not have to pay for the four simple extractions (D7140 x4) provided from June 22, 2021, to August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Supatz-FX.  You asked the Plan to pre-approve Supatz-FX. You say that this is medically necessary to help you walk and with your pain. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Supatz-FX. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found you have osteoarthritis of the knee. The documentation does not support that you have trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the Plan's additional required drugs would likely be less effective and/or likely have adverse effects for you. Therefore, you do not meet criteria for the requested drug.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supatz-FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supatz-FX.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99214) provided June 30, 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 claim cannot be paid 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 find that CPT code 99214 is not supported in the medical record. Specifically, the use of modifier 25 is not supported. Claim history shows no record of a non-evaluation and management 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 (99214) provided June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laser treatment services provided on July 6, 2021.  You asked the Plan to pay for the laser treatment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.      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 laser treatment services. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our reviewer found the enrollee has a diagnosis of vitiligo. The documentation does not support that psoriasis was documented in the enrollee's history or examination. The enrollee's vitiligo appears to be cosmetic in nature as no signs or symptoms related to the condition or any accidental injury or any dysfunctional malformed body member are reported other than depigmented patches. Therefore, the enrollee did not meet criteria for the services rendered.  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 laser treatment services have not been met. Therefore, we decided that the Plan does not have to pay for the laser treatment services provided on July 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 14, 2020, to May 20, 2021, by a provider not enrolled in the Medicare program.  You asked the Plan to pay for psychotherapy services. You say that the enrollee has developed a good working relationship with the provider of the services at issue and the services should be covered for continuity of care. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 14, 2020, to May 20, 2021, by a provider not enrolled in the Medicare program.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 testing is not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series or radiographic images (D0210), prophylaxis (D1110), and adjunctive pre-diagnostic test (D0431), provided on June 29, 2021.  You asked the Plan to pay for the comprehensive oral evaluation, complete series or radiographic images, prophylaxis, and adjunctive pre-diagnostic test. You say that the services should be covered. The Plan denied your request. The Plan says your benefits have been exhausted.  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 comprehensive oral evaluation (D0150), complete series or radiographic images (D0210), prophylaxis (D1110), and adjunctive pre-diagnostic test (D0431), provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for negative pressure wound therapy (97606) provided on August 1, 2020.  You asked the Plan to pay for negative pressure wound therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.  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.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records do not indicate that this was performed in a separate encounter, procedure, or site than the column I procedure 13160. 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 negative pressure wound therapy (97606) provided on August 1, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency department visit (99283) rendered on May 4, 2021.  You asked the Plan to waive the copayment for an emergency department visit. You say that you believe the denial is incorrect because the Plan is the supplemental health insurance and should cover this bill. You also say that supplemental insurance is for whatever is not covered by Medicare, at least that is how you understand it. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $50 copayment for an emergency department visit.  You have been asked to pay a $50 copayment for an emergency department visit. 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 emergency department visit (99283) rendered on May 4, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 You asked the Plan to pay for cochlear implant reprogramming. You say that this code billed in isolation can reflect unilateral cochlear implant reprogramming, but modifiers can be used to indicate bilateral programming. The Plan says that the denial of payment for these services is correct, because this code must be billed with 1 unit of service and there is no additional payment for the code if reported as a unilateral or bilateral procedure.   We decided that the Plan has to pay for cochlear implant reprogramming.   The Plan follows Medicare rules. Medicare rules state that code 92604 has a bilateral indicator of 0. Medicare rules state that if this procedure is reported with modifiers -RT and -LT, payment for the two sides is based on the lower of the total actual charge for both sides or 100% of the fee schedule amount for a single code.  You billed this procedure with codes 92604-LT and 92604-RT. Although the Plan is correct that no additional payment for this code is made if reported as unilateral or bilateral, the record shows that the Plan has not issued any remittance for this procedure in the first place. The Plan must pay for these codes based on the lower of either the total actual charge for both sides ($312), or 100% of the fee schedule amount for a single code. Therefore, we decided that the Plan has to pay for cochlear implant reprogramming.   We also decided that the Plan does not have to pay the full claimed billing for cochlear implant reprogramming.  The Plan follows Medicare rules. Medicare rules state that code 92604 has a bilateral indicator of 0. Medicare rules state that if this procedure is reported with modifiers -RT and -LT, payment for the two sides is based on the lower of the total actual charge for both sides of 100% of the fee schedule amount for a single code.  You have billed this procedure with a total claimed amount of $312. However, the Plan must only remit the lower amount of either the total actual charge or 100% of the fee schedule amount for a single code. Once the Plan has issued this remittance, no additional payment is made for these codes. Therefore, we decided that the Plan does not have to pay for cochlear implant reprogramming.  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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 14, 2021.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing the service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services (16020) provided on February 26, 2021.

You asked the Plan to waive the copayment for surgical services. You say that the services should be covered as you were not advised it would be an outpatient procedure. The Plan denied your request. The Plan says the copayment applied correctly based on 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 $250 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $250 copayment for surgical services. The record shows that the services were provided in an outpatient facility. Surgical services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 surgical services (16020) provided on
February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided from November 11, 2020, to November 14, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis code is not supported.  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 A41.9. 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 services. Our reviewer says that the billed diagnosis code is not supported. Our physician reviewer found that tachycardia and leukocytosis, with treatment of IV antibiotics, are consistent with the diagnosis of acute cholecystitis and do not reflect a life-threatening organ dysfunction from a dysregulated host response to infection. A procalcitonin level of 6.04 ng/mL was noted the morning following surgery, however, this is not consistent with life threatening organ dysfunction. The review has determined that the use of primary diagnosis code A41.9 is not supported by the records provided.   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 the inpatient hospital services provided from November 11, 2020, to November 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic office visits (99214, 99205).

You asked the Plan to pre-approve chiropractic office visits. You say that you need to see a chiropractor 3
times a week. The Plan denied your request. The Plan says office visits are not a covered chiropractic service.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve chiropractic office visits (99214, 99205).