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

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided January 29, 2021 to February 27, 2021.  

You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not medically necessary.  

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee required supervision/touch assistance level to contact guard/minimal assistance including walking to 250 feet with a wheeled walker. The documentation does not support that the enrollee required the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that the enrollee required services on a daily basis in the SNF.  

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided January 29, 2021 to February 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 9, 2020 to December 10, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the plan partially recouped and adjusted the claim and updated the 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.    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 services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the enrollee presented to the emergency department on 12/9/20220 with right upper quadrant pain rated 10/10 and was diagnosed with acute pancreatitis. The enrollee remained hemodynamically stable and was tolerating a liquid diet. The enrollee left the hospital against medical advice on 12/10/2020. The discharge diagnosis was acute pancreatitis with mild distension of the common bile duct. There was no evidence of sepsis. The review has determined that the records did not support the DRG and the diagnosis codes reported.   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 hospital services provided to the enrollee from December 9, 2020 to December 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for neurology services provided to the enrollee on July 23, 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 the denied codes remain 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 the denied codes is:  

CPT 95886:  

Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)  

CPT 95913:  

Nerve conduction studies; 13 or more studies  

CPT 95937: 

 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method  

CPT 95955:  

Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)  

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 per the CPT code description for 95886, this procedure is done with nerve conduction studies. As nerve conduction studies cannot be verified in the procedure performed, this service would not be covered. In terms of CPT 95913, the documentation describes pedicle screw stimulation performed and reported with nerve conduction studies procedure code. Nerve conduction studies is an incorrect code to report for pedicle screw stimulation. Nerve conduction studies measure amplitude, latency, and conduction velocity. Pedicle screw stimulation testing performed during intra-operative monitoring is included in the EMG monitoring and should not be billed as nerve conduction studies. In terms of CPT 95937, the procedure report describes train of four testing, and is reported with the neuromuscular junction testing procedure code. This is an incorrect procedure code to report for this service. Train of four is bundled with the intraoperative neuromonitoring of EMG or MEP and is not separately reported. There is no CPT code for train of four monitoring. In terms of CPT 95955, this code falls under "Special EEG testing." Any additional EEG testing would be included in the primary neuromonitoring procedure, and should not be reported separately.  

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 neurology services provided to the enrollee on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing provided on August 3, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the OON lab testing. You say that this was medically necessary and could not be provided in-network. The Plan denied your request. The Plan says this was not authorized to be provided out of network and was not ordered by a network provider. No referral was made by the primary care physician for these services.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on August 3, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and resin-based composite (D2331) provided on March 29, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, prophylaxis, topical application of fluoride varnish, and resin-based composite. You say that your benefit booklet shows a $0 copayment for these services, whether they are provided in-network or OON. The Plan denied your request. The Plan says the total $295 amount applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.  

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, you are responsible for the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and resin-based composite (D2331) provided on March 29, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 3, 2021, to June 3, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the services you received were ineffective; therefore, you think the Plan should pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $290 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $290 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,450 ($290 x 5 days = $1,450). Since inpatient services were provided, the correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 3, 2021, to June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have  genetic testing services provided to the enrollee on June 29, 2021.  

You asked the Plan  the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not show that future treatment with chemotherapy, which is a requirement for being approved for the requested service.  

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  the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the records do not show that the enrollee will be treated with chemotherapy, which is a requirement for being approved for the requested service. She has been directed to receive palliative care. The review indicates that the enrollee does not meet the criteria for this testing.  

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 services have not been met. Therefore, we decided that the Plan does not have  genetic testing services provided to the enrollee on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services (S9338, 99601, and 99602) provided on February 25, 2021 and February 26, 2021.  

You asked the Plan to pay for codes S9338, 99601, and 99602. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We looked at the file and Medicare rules. In this case, CPT codes S9338, 99601, and 99602 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9338, 99601, and 99602) provided on February 25, 2021 and February 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450-26) provided to the enrollee on November 29, 2020.  You asked the Plan to pay for the CT scan. 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 CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. 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 CT scan, head or brain; without contrast material (CPT code 70450-26) provided to the enrollee on November 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on July 1, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that it was medically necessary for Lifeline to call the ambulance since you were having an unpredictable memory break down crises, which was later diagnosed as a stroke and memory loss. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.  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 July 1, 2021. 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 ambulance response and treatment, no transport provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the respiratory syncytial virus and Staphylococcus aureus testing provided on August 4, 2020, billed with codes 87634 and 87640.  

You asked the Plan to pay for the testing as billed. You say that this is medically necessary testing that should be paid. The Plan denied your request. The Plan says these two codes were not billed with the appropriate modifier.  

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 87640 is a Column 2 code in relation to 87641, and that 87634 is a Column 2 code in relation to 87798. This claim has not been billed with appropriate modifiers to bypass the edits. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory syncytial virus and Staphylococcus aureus testing provided on August 4, 2020, billed with codes 87634 and 87640.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on June 17, 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 the records do not support the services 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.  In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older."  We 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 the medical records provided does not include sufficient documentation to support billing 99152, therefore this procedure cannot be verified.  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 anesthesia services provided to the enrollee on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation and management (EM) services and electrocardiogram (EKG) provided on August 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the EM services and EKG. You say that this should be paid due to medical necessity. The Plan denied your request. The Plan says this was a non-emergent visit that was not authorized to be provided OON.    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 evaluation and management (EM) services and electrocardiogram (EKG) provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (procedure codes 36215 and 75710) provided to the enrollee on May 11, 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 the denied codes remain 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 the denied codes is:  

CPT 36215:  

Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family  

CPT 75710:  

Angiography, extremity, unilateral, radiological supervision and interpretation  

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 that in terms of CPT 36215, the operative report does not include enough detail of the procedure performed to determine the correct procedure code. The procedure report does not include enough detail to confirm an appropriate CPT code. The documentation does not include the details of the procedure. Catheterizations performed from vessel punctures other than direct puncture of the dialysis circuit may be separately reported. In terms of CPT 75710, the documentation does not include documentation of radiological supervision and interpretation of unilateral extemity angiography. This procedure cannot be confirmed as performed.  

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 (procedure codes 36215 and 75710) provided to the enrollee on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 23, 2021, to June 10, 2021.  

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.  

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 $295 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.   

You have been asked to pay less than a $295 copayment per day for days 1-5 for an inpatient hospital stay. You are only being asked to pay $760, which is less than your copayment amount of $1,475 ($295 x 5 days = $1,475), due to reaching your out-of-pocket maximum allowance amount of $6,700. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided by a participating provider on May 23, 2021, to June 10, 2021.