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

We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 19, 2021, to March 31, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because you were never informed that you would owe anything for the stay. 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 $0 copayment for days 1-20 and a $150 copayment for days 21-40 for SNF care. 

You had a SNF stay from March 19, 2021, to March 31, 2021. The record shows that you had a previous SNF stay for a total of 20 days. Therefore, you are responsible to pay a $150 copayment for days 21-33 (March 19, 2021, to March 31, 2021). The total amount you owe is: $150 (copayment) x 13 (SNF days) = $1,950. 

You have been asked to pay the total copayment amount of $1,950 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from March 19, 2021, to March 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 97032, 97750, 96372 x 2, 97112, 97016, J3490 x 5, J3411, J3415, J7999 x 2, and 97139 provided on March 8, 2021.

You asked the Plan to pay for the outpatient physical therapy and drug administration services. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says the services provided are not covered.

The Plan must follow Medicare rules. Medicare rules say that outpatient physical therapy services are payable only if they are furnished by, or under the direct supervision of a physical therapist in private practice. The rules also say in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient PT and drug administration services have not been met. Specifically, review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by a nurse practitioner (NP)/physician assistant (PA) who is not licensed to provide physical therapy in the State of Oklahoma. Additionally, payment for HCPCS/CPT codes 96372, J3490, J7999, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Therefore, we decided that the Plan does not have to pay for procedure codes 97032, 97750, 96372 x 2, 97112, 97016, J3490 x 5, J3411, J3415, J7999 x 2, and 97139 provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for periodontal maintenance (D4910) provided by an out-of-network provider on June 17, 2021.  You asked the Plan to waive the deductible for periodontal maintenance. You say that you were informed that everything would be covered. The Plan denied your request. The Plan says the correct deductible has been applied.  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 $50 deductible which applies to basic and major dental services.    The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $50 deductible which applies to basic and major dental services. This cost sharing is a contractual obligation that had not been met at the time periodontal maintenance was received on June 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for periodontal maintenance (D4910) provided by an out-of-network provider on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit you had with a physical medicine specialist on June 29, 2021.  You asked the Plan to waive the copayment for the physical medicine specialist visit. You say that this provider is in-network, so there should be no copayment. 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 ($34.89) 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 $45 copayment for visits with a specialist.   You have been asked to pay a $45 copayment for the physical medicine specialist visit. This is the in-network cost sharing for a specialist 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 the office visit you had with a physical medicine specialist on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on June 10, 2020. You asked the Plan to pay for the services provided. You say that the medical record supports the assignment of the secondary diagnosis. The Plan denied your request. The Plan says the inpatient services were reported with the incorrect DRG.  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 secondary diagnosis G93.41, defined as metabolic encephalopathy. 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 provided. Our physician reviewer found that the enrollee presented to the emergency room after being found unresponsive to stimuli with pinpoint pupils. He was documented with an altered mental status, lethargic and obtunded in the emergency department. The admitting physician documented in the history and physical that upon evaluation, the enrollee was more alert and able to respond to commands, but still confused as to where he was and why. The admitting physician also documented that he appeared to be back at his baseline mental status. The review has determined that the records provided did not support the billed secondary diagnosis code.   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 on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87481, 87500, 87529) provided on May 16, 2021.  You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87500, 87529) provided on May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for periodontal scaling and root planing, localized delivery of antimicrobial agents and gingival irrigation provided on August 4, 2021.  You asked the Plan to pay for periodontal scaling and root planing, localized delivery of antimicrobial agents and gingival irrigation. You say that they gave you an estimated cost of $1,509.50 for the services after an insurance benefit of $742.50. You say that you would not have agreed to these services if you had known insurance would not cover anything. The Plan denied your request. The Plan says the services are not covered benefits.  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 periodontal scaling and root planing, localized delivery of antimicrobial agents and gingival irrigation provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing provided on June 14, 2021. You asked the Plan to pay for the testing services. You say that the testing is validated in peer-reviewed journals. The Plan denied your request. The Plan says there is inconclusive evidence that this testing can be used to safely monitor for the recurrence of bladder cancer.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. In this case, there are sufficient medical records to show the use of biomarkers will be used to assist in the management and treatment of the enrollee. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on September 22, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the physician provided care without authorization to avoid delay in care. The Plan denied your request. The Plan says the services require prior authorization.

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 services 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 the wound care services provided on September 22, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381 x 4) provided on January 5, 2021.  You asked the Plan to pay for the dental services. You say that the antibiotic charge was not paid in full. You say that the antibiotic charge for each tooth was $28. You say that only $56 of the total $112 was paid. You also say that the remaining $56 should be paid. The Plan denied your request. The Plan says there is a 50% copayment for localized delivery of antimicrobial agents. The Plan also says that the claim was processed correctly.  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 and the service is listed as covered, the there is a 50% copayment that applies. This is a contractual obligation of the plan and cannot be waived. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381 x 4) provided on January 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiological services provided on March 26, 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 are not payable.  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 file shows that codes 75726 and 75774 were billed with a -59 modifier. The medical records provided do not show that the services billed with the -59 modifier is a distinct procedural service. The records show that the diagnostic services were performed as part of revascularization procedure (Code 37224). 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 radiological services provided on March 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy evaluation provided by a physical therapist on February 5, 2020.    You asked the Plan to pay for the physical therapy evaluation. You say that plans are required to pay non-contracted providers at the preferred provider rate when 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 code is not appropriate for the service billed.  The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services.  Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation provided by a physical therapist on February 5, 2020.
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 you are struggling to perform regular activates as normal. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  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 that you are medically stable and do not meet coverage criteria for an IRF admission. With your current medical stability, and no other medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs. At the current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Your rehabilitation needs can be addressed just as well in-home with therapies. IRF admission is not medically necessary based on functional level and lack of medical complexity. Documentation does not support the necessity for admission to IRF. While you may benefit from continued physical therapy and occupational therapy, your rehabilitation needs can be safely met in an alternate and low intensity setting.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on October 28, 2020.  You asked the Plan to pay for the testing services. You say that medical records substantiate the necessity of services. The Plan denied your request. The Plan says experimental or investigational services are 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.  We looked at the file and the rules. The medical records do not show the treating physician's intent for the services to be provided. The records do not show that the results of testing will impact clinical management to improve the enrollee's outcomes. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram provided on January 14, 2021.

You asked the Plan to pay for the testing services. You say that the information supports the services. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The file shows that the enrollee received intraoperative neuromonitoring services. In this case, the CPT Code Manual definition of code 95822 is electroencephalogram (EEG); recording in coma or sleep only. We find that CPT code 95822 is not supported in the medical record. There is a more comprehensive code that describes the services provided. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram provided on January 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services are not reasonable in terms of the amount, frequency, and duration.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on April 6, 2021, to April 19, 2021.

You asked the Plan to pay for the provided device. You say that complications and risk factors can be minimized with the use of the device. The Plan denied your request. The Plan says the device is not covered to prevent deep vein thrombosis during or following surgery.

The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered under certain medical indications.

The file shows that a pneumatic compression device (E0675) and segmental gradient pressure appliance (E0673) were provided. We looked at the file, and Medicare rules. There is insufficient evidence to justify the use of the provided pneumatic compression device. If the base device is not covered, related accessories are not eligible for reimbursement. Based on this information, we decided that Medicare rules for coverage of the provided device have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on April 6, 2021, to April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the imaging services rendered on April 14, 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 procedure code 75710 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 75710 (unilateral extremity angiography) and 37225 (endovascular revascularization). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37225. Code 75710 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the imaging services rendered on April 14, 2021.