Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services (S9122) provided from April 9, 2021, to April 20, 2021.
You asked the Plan to pay for the home health services. You say that the enrollee requires round the clock care. You say that the services should be covered. The Plan denied your request. The Plan says you did not require skilled nursing care on the dates of service in this case. The Plan also says that the claim was denied correctly.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home health aide services (S9122) provided from April 9, 2021, to April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the hip surgery provided on June 30, 2021.

You asked the Plan to reduce the coinsurance for the hip surgery. You say that you were incorrectly billed as outpatient. You say you were an inpatient. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 15% coinsurance for Medicare-covered outpatient hospital services, outpatient observation and outpatient surgery.

We decided that the Plan does not have to reduce the coinsurance for the hip surgery provided on June 30, 2021.
You asked the Plan to reduce the coinsurance for the hip surgery. You say that you were incorrectly billed as outpatient. You say you were an inpatient. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 15% coinsurance for Medicare-covered outpatient hospital services, outpatient observation and outpatient surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance services coded 77003 provided on October 30, 2020.
You asked the Plan to pay for the fluoroscopic guidance 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 separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77003 for the fluoroscopic guidance services is a column II code to column I code 64635. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance services coded 77003 provided on October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says a home assessment with a written report should be completed prior to delivery of
the power mobility device.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, there is inadequate documentation that this enrollee has a personal mobility deficit
that impairs participation in the mobility-related activities of daily living such as toileting, feeding, grooming,
and bathing in customary locations within the home. A written assessment from the enrollee's medical provider
reports a significant mobility impairment, but the physical examination performed at the time of this statement
contains conflicting information regarding muscle weakness and the examination does not describe the
enrollee's gait or mobility impairment. There is a statement that the enrollee's mobility deficit cannot be helped
using a walker, cane, or manual wheelchair; however, the physical examination reported does not support this.
The records do not document that the enrollee's home has been evaluated to ensure that it could safely support
the use of the requested power wheelchair.

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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 7, 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 these codes are not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code is not supported in the medical record. Specifically, most of these codes a status indicator of B according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral to a general surgeon.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show a need for a tertiary level of care.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had undergone surgery by the requested provider in January 2021. The record indicates that at a follow up visit in March the enrollee had resolution of symptoms. The record provided is insufficient to determine the medical necessity at this time to receive the requested services. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level referral to a general surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to show that this device is as safe and effective as the gold standard of surgical decompression.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental in spine surgery. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) capture and interpretation (D0369) provided on August 25, 2021.
You asked the Plan to pay for the MRI capture and interpretation. You say that you were advised by a plan representative to go out of network as there were no in network providers available. You say that you were advised the services would be covered at 100%. You say that you received a bill for the services you received. You also say that you were given incorrect information multiple times by plan representatives.
The Plan denied your request. The Plan says magnetic resonance imaging (MRI) capture and interpretation is not listed as a covered service.
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 service you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) capture and interpretation (D0369) provided on August 25, 2021.
Your complaint about misled by plan representatives is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76700) provided August 19, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 has a bundled relationship with code 93976.

This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76700) provided August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) (70544) provided on July 12, 2021.

You asked the Plan to pay for the MRA. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between 70551 and 70544.

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 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) (70544) provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health stay provided by an out-of-network
provider on March 4, 2021, to March 8, 2021
You asked the Plan to pay for inpatient mental health stay. You say that these services were medically
necessary in order to observe and monitor to ensure for safe return to the community. The Plan denied your
request. The Plan says the enrollee could have been treated in a lower level of care, such as outpatient
treatment.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 mental health stay. Our reviewer
says that it did not appear medically necessary and reasonable to have psychiatric care provided at the acute
inpatient level of care rather than a lower level of care. Our physician reviewer found it was not expected that
this enrollee would improve in a reasonable period of time, as he did not have dangerousness to self or others,
auditory or visual hallucinations, delusions and was not showing any behavioral issues after March 5, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health stay have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient mental health stay provided by an out-of-network provider on March 4,
2021, to March 8, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services at a radical resection of tumor
(28046) and draining or injection of an intermediate joint (20605) provided on July 16, 2021.

You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 28046 and 20605. The Medicare Fee Schedule Database contains a
surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon
is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage
criteria for surgical assistant services have not been met.

Therefore, we decided that the Plan does not have to pay for surgical assistant services at a radical resection of
tumor (28046) and draining or injection of an intermediate joint (20605) provided on July 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on August 31, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that you are appealing this bill. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $30 copayment for basic radiological services at an in-network specialist's office. 

You have been asked to pay a $30 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the x-ray provided on August 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 home health skilled nursing visit.
You asked the Plan to pre-approve 1 home health skilled nursing visit. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 1 home health skilled nursing visit. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical
records provided there is no documentation that additional skilled nursing services beyond what have already
been approved are required to effectively provide treatment, care, and/or services in order to improve your
condition, or to establish/perform a maintenance program to maintain your condition and/or prevent
deterioration. Records do not document any acute or unstable medical conditions or changes in medication or
treatment which would necessitate any further skilled nursing visits beyond what have already been approved.
No medical notes from your treating physician are provided documenting an order or need for additional
skilled nursing services beyond what have already been approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 1 home health skilled nursing visit have not been met. Therefore, we decided
that the Plan does not have to pre-approve 1 home health skilled nursing visit.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided from June 22, 2021 to
July 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 services provided from June 22,
2021 to July 12, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on August 13, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 services provided on August 13, 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 coded as 36246 and 75716.

You asked the Plan to pay for the medical services. You say that you would like these services reprocessed and approved for payment. The Plan denied your request. The Plan says the records do not support payment for the services 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. 

In this case, the CPT Code Manual definition of code 36246 is selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family. The CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, 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 medical services. Our reviewer says that the documentation does not support the codes as billed. Our reviewer found the documentation submitted was reviewed and the criteria for coverage have not been met. Regarding CPT 36246, selective catheter placement is documented in the procedure report, however, this procedure would be bundled into CPT 37228, as both angiography and intervention was performed from same puncture site. For CPT 75716, radiological supervision and interpretation would be performed for revascularization procedures, and would be inclusive to the primary procedure. 

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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 36246 and 75716.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on June 9, 2021.

You asked the Plan to pay for the services provided. You say that the documentation supports medical necessity. The Plan denied your request. The Plan says the panel is non-covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

The file shows that FoundationOne testing was provided. We looked at the file, and Medicare rules. The rules say that the testing at issue is unlikely to impact decision making for the enrollee. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on June 9, 2021.