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

We decided that the Plan does not have to pay for the observation care discharge day management coded 99217 provided on May 8, 2021.

You asked the Plan to pay for the observation care discharge day management. 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 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).

We find that CPT code 99217 is not supported in the medical record. Specifically, there is no qualifying initial or subsequent observation care services found in the enrollee's claim history. There was no appropriate service billed prior to this discharge service. This means this discharge code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the observation care discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the observation care discharge day management coded 99217 provided on May 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on May 28, 2021.
You asked the Plan to pay for the services provided. You say that the test results were needed to help determine
the course of treatment for the enrollee. The Plan denied your request. The Plan says the billed code is noncovered.
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 a FoundationOne Heme test was provided and billed with code 81455. We looked at the
file, and Medicare rules. The genetic testing at issue is unlikely to impact therapeutic decision-making in the
clinical management of 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 May 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuropsychological testing evaluation (96132 and 96133) and psychological or neuropsychological test administration and scoring (96136 and 96137) provided on September 21, 2020.

You asked the Plan to pay for the neuropsychological testing evaluation and psychological or neuropsychological test administration and scoring. You say that you believe these services were provided in good faith. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the neuropsychological testing evaluation (96132 and 96133) and psychological or neuropsychological test administration and scoring (96136 and 96137) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory 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 laboratory services provided on May 6, 2021
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobility scooter you purchased on May 28, 2021.

You asked the Plan to pay for the mobility scooter. You say that you needed this item to be able to cope because you are no longer able to drive. The Plan denied your request. The Plan says this item is not covered for you because you will only be using it outside of the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the mobility scooter you purchased on May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from July 25, 2021, through July 27, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that the hospital gave you excessive insulin and it took several days to wean off. You say that you felt like you had dementia during the visit, and you should not have to pay. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. The emergency room copayment applies if you are in the hospital for observation or rapid treatment as these are not considered hospital admissions.

You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency 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 the ER visit provided from July 25, 2021, through July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on August 6, 2021, by an OON
provider.
You asked the Plan to pay for the duplex scan. You say that authorization is not needed for the current
procedural terminology (CPT) 93880. The Plan denied your request. The Plan says no prior authorization was
obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the duplex scan provided on August 6, 2021, by an OON
provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 January
25, 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 does not include a critical care evaluation and management note supporting 30-74 minutes of critical care for this date of 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 January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on November 4, 2019.
You asked the Plan to pay for the services provided. You say that the monitoring is an integral part of neurosurgical procedures. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 looked at the file and the rules. We find that CPT codes 95813, 95887, and 95907 are not supported in the medical record. Specifically, the billed codes do not accurately describe the services provided to 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 intraoperative neuromonitoring services provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the free soft tissue graft procedure of the first tooth (D4277) and free soft tissue graft procedures of three additional contiguous teeth (D4278 x3) provided on August 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the free soft tissue graft procedures. You say that you tried to find an in-network provider. You also say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that 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 also does not cover services that are rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the free soft tissue graft procedure of the first tooth (D4277) and free soft tissue graft procedures of three additional contiguous teeth (D4278 x3) provided on August 26, 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 therapeutic procedures coded 97110 and 97112, the therapeutic activities coded 97530, and the self-care/home management training coded 97535 provided from June 21, 2021 to July 3, 2021.

You asked the Plan to pay for the therapeutic procedures, the therapeutic activities, and the self-care/home management training. 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. 

We find that CPT codes 97110, 97112, 97530, and 97535 are not supported in the medical record. Specifically, the documentation shows that these services were performed by a physical therapist in a home health or hospice setting. This means there are more appropriate codes to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures, the therapeutic activities, and the self-care/home management training have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures coded 97110 and 97112, the therapeutic activities coded 97530, and the self-care/home management training coded 97535 provided from June 21, 2021 to July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on August 6, 2021.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.

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 initial hospital care. Our reviewer says that CPT code 99223 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation supports a comprehensive history as 3 conditions were addressed in the history, 11 systems were reviewed for a complete Reactive Oxygen Species level, and a Complete Past, Family and/or Social History was performed. A comprehensive exam was performed as 10 organ systems were assessed. Documentation supports Medical Decision Making Low Complexity. Documentation supports presenting problem - high; diagnostic procedures - minimal and management options - low. There is a more appropriate code to report for the services rendered.

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 initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on AUgust 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided on July 27, 2021.

You asked the Plan to pay for the services provided. You say that the enrollee was discharged on July 27, 2021. The Plan denied your request. The Plan says the documentation does not support the services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and the rules. The documentation in the case file does not support the billed services. Specifically, there are no ambulance records provided for the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on September 3, 2021.

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the code was not billed with an allowed modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

The file shows that CPT code 70450 was billed along with code 70496 on the date of service at issue. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on September 3, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for transverse myelitis.
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services (95885, 95907, and 95955)
provided on July 7, 2021.
You asked the Plan to pay for codes 95885, 95907, and 95955. You say that the medical records support the
billing of codes 95885, 95907, and 95955 provided on July 7, 2021. The Plan denied your request. The Plan
says the medical records do not support the billing of codes 95885, 95907, and 95955 provided on July 7, 2021.
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 95885 is Needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
limited (List separately in addition to code for primary procedure).
The definition of code 95907 is Nerve conduction studies; 1-2 studies. The definition of code 95955 is 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 codes 95885, 95907, and 95955. Our reviewer says that the medical records do not support the billing of codes 95885, 95907, and 95955 provided on July 7, 2021. Our reviewer found the documentation submitted for review does not support the billing of code 95885. Per CPT 95885 description, this procedure is done with nerve conduction studies. Documentation does not support nerve conduction studies were performed; therefore, this service would not be covered. Per CPT 95907, the technical report describes "pedicle screw stimulation" was performed and reported with CPT 95907. This is an incorrect code to report for the procedure documented. Nerve conduction studies measures latency, amplitude, and conduction velocity. These were not documented in the procedure report, and therefore this procedure cannot be verified. Per CPT 95955, this code applies to an EEG during surgery exclusive of surgery to the brain. This description was not documented in the operative report narrative. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95885, 95907, and 95955 have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services (95885, 95907, and 95955) provided on July 7, 2021.