Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 30, 2019.
You asked the Plan to pay for physical therapy services. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers. 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 records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transurethral electrosurgical resection of prostate (TURP) surgery provided from May 20, 2021 to May 21, 2021.
You asked the Plan to waive the copayment for TURP surgery. You say that you went to the hospital through the emergency room and were not expecting a bill. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $350 copayment for outpatient TURP surgery in an outpatient hospital facility.
You have been asked to pay $350 copayment for TURP surgery. TURP surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for transurethral electrosurgical resection of prostate (TURP) surgery provided from May 20, 2021 to May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions, residual tooth root removal, bone replacement graft, limited oral evaluation and intraoral x-ray provided on March 23, 2021.
You asked the Plan to pay more for the extractions, residual tooth root removal, bone replacement graft, limited oral evaluation and intraoral x-ray. You say that the provider refused to fill out the paperwork but you provided as much information that you could gather. You say that the dentist was listed as a network provider. The Plan denied your request. The Plan says payment was approved for the extractions, residual tooth root removal and bone replacement graft. The limited oral evaluation and intraoral x-ray are not covered because your $1,000 maximum was exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay $1,000 for your covered comprehensive dental services every year. Therefore, we decided that the Plan does not have to pay more for the extractions, residual tooth root removal, bone replacement graft, limited oral evaluation and intraoral x-ray provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on February 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function". We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that the documentation must support 3 of 3 key components for emergency room visit. In this case, the documentation supports a comprehensive history, a problem focused exam as only vital signs are documented and medical decision making of moderate complexity. The documentation supports code 99281. 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 (99285) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on March 17,
2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because
the billed services were medically necessary. The Plan denied your request. The Plan says Medicare coverage
criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that you must attempt to consult their attending or
primary care physician about provided services and either document consent or declination date to
consultations and date of consultations in patient's medical record.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy services have not been met. Specifically, claim does not include a referring
provider and there is no documentation that this provider attempted to consult the member's primary care
physician about the services rendered. Therefore, we decided that the Plan does not have to pay for the
psychotherapy services (90832) provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation discharge care (99217) provided April 2, 2021.
You asked the Plan to pay for the observation discharge care. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed CPT code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99217 is not supported in the medical record. Specifically, no initial or subsequent observation care service was billed. Without an initial or subsequent service, the discharge service cannot be supported. Based on this information, we decided that Medicare rules for coverage of the observation discharge care have not been met. Therefore, we decided that the Plan does not have to pay for observation discharge care (99217) provided April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided to the enrollee on March 9, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 office visit (CPT code 99214) provided to the enrollee on March 9, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 21, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography, head or brain (70450) provided April 22, 2021.
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing The Plan denied your request. The Plan says unbundled service. The records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496.
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 the diagnostic service has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography, head or brain (70450) provided April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the triamcinolone acetonide injection (J3304) provided on March 29, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% of the total cost up to a $300 quarterly maximum for in-network Medicare Part B Chemotherapy Drugs, associated administration services and all other Medicare Part B drugs.
You have been asked to pay $57.63 (Plan allowed amount of $576.32 x 10% coinsurance) for the Medicare-covered Part B drug injection provided. 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 coinsurance for the triamcinolone acetonide injection (J3304) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 7, 2020.
You asked the Plan to pay for this service. . You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found documentation does not support the need for an admission to an SNF. Your rehabilitation needs can be met at a lower intensity level such as in a long-term care (LTC) facility with intermittent therapies as needed. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection of betamethasone acetate and
phosphate (a Medicare Part B drug) and arthrocentesis procedure provided on July 12, 2021.
You asked the Plan to waive the cost-sharing for Part B drug and podiatry service. You say that you were told
you would not have to pay the specialist copayment because all you were getting was an injection. The Plan
denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 20%
coinsurance for Part B drug and $35 copayment for podiatry visit. The allowed amount of the injection is
$6.63, resulting in a coinsurance amount of $1.33. Your total cost-sharing obligation is therefore $36.32.
You have been asked to pay 20% coinsurance for Part B drug and $35 copayment for podiatry visit. Part B
drug and podiatry service fall within the "Medicare Part B Prescription Drugs" and "Podiatry Services" benefit
categories. 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 cost-sharing for an injection of betamethasone acetate and
phosphate (a Medicare Part B drug) and arthrocentesis procedure provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided on June 3, 2021.
You asked the Plan to pay for out of network services. You say that this claim should be paid The Plan denied
your request. The Plan says you did not have prior authorization for out of network care.
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 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 out-of-network
physician services provided on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography represented by code 70544 provided on May 4, 2021.
You asked the Plan to pay for code 70544. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 represented by code 70544 provided on May 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) skilled nursing (LPN) visits (CPT code G0300).
You asked the Plan to pre-approve the skilled nursing visits. You say that you need three (3) days a week of home health instead of the two (2) visits. You state you are not able to wrap your wound yourself and the wound needs to be changed more than twice a week. The Plan denied your request. The Plan says based on review of the clinical information, you had a recent hospital stay for a right hip fracture that required surgical repair and you were then discharged to a skilled nursing facility for further rehabilitation. The Plan states you currently have wounds to both legs that require management from a skilled nurse. The Plan states while you have ongoing home health care needs, you do not the full amount of skilled nursing (LPN) visits at this time. The Plan states additional clinical information will be needed from the home health provider once these approved visits are completed, before any additional visits can be considered for approval and the information needs to specifically address your progression with home health care and all associated treatments, as well as a continued need for home health care.
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 the skilled nursing visits. Our physician reviewer found the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You are receiving twice weekly wound care. The wounds are not infected. There is someone in the home that is willing to assist you if needed. The requested home health services are not medically necessary. 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) skilled nursing (LPN) visits (CPT code G0300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablets.
You asked the Plan to pre-approve Ondansetron tablets. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.
Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 26, 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 codes 29879 and 29876 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 29879 is arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture. The definition of code 29876 is arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral).
We find that procedure codes 29879 and 29876 are not supported in the medical record. Specifically, there is no documentation of a surgical knee arthroscopic abrasian arthroplasty to support code 29829. There is no documentation of a surgical knee arthroscopy with synovectomy to support code 29876. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 26, 2021.