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

 We decided that the Plan does not have to pay for the perfusion services rendered on June 17, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code A9500 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 A9500 is Technetium tc-99m sestamibi, diagnostic, per study dose.  We find that CPT code A9500 is not supported in the medical record. Specifically, the file shows that a qualifying imaging procedure was not billed with the code. 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 perfusion services rendered on June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monovisc.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc.   Benefits for these services 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on December 28, 2020.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says your Plan covers ambulance transportation only when you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not covered under your Plan.  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 December 28, 2020. 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 (A0998) provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia service (99100) provided on January 7, 2021.  You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment, and if it is covered the payment for it is subsumed by the payment for services to which it is incident.   We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on January 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on June 9, 2021.  You asked the Plan to pay for laboratory services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. 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 laboratory services provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional unit of initial hospital care (99223) provided on March 17, 2021.  You asked the Plan to pay for the additional unit of code 99223. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says only one unit of code 99223 is supported in the medical record.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that 2 units of CPT code 99223 are not supported in the medical record. The medical record only supports 1 unit of CPT code 99223.  Based on this information, we decided that Medicare rules for coverage of the additional unit of code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for the additional unit of initial hospital care (99223) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia service (99100) provided on May 11, 2021.  You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment, and if it is covered the payment for it is subsumed by the payment for the services to which it is incident.   We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 11, 2021, to May 24, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were in another hospital for 5 days starting on April 29, 2021.  They sent you home with antibiotics.  You were then readmitted to a different hospital from May 11, 2021, to May 24, 2021. You said that you were not happy with the hospital from the first admission and you don't think you should have to pay two separate copayments. The Plan denied your request. The Plan says you were charged this copayment 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 $600 copayment per admission for inpatient hospital services.   You have been asked to pay a $600 copayment per admission for the inpatient hospital services. This copayment applies per admission, regardless of the reason for the admission or your satisfaction with the services received. 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 inpatient hospital services you received from May 11, 2021, to May 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for office visits (99213) and an annual wellness visit (G0438) rendered from February 12, 2021, to May 26, 2021.  You asked the Plan to waive the coinsurance for office visits and an annual wellness visit. You say that you feel you should have no copayment. The Plan denied your request. The Plan says that you were charged the correct cost sharing amount.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.   The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any evidence of how they calculated your coinsurance or your deductible. In fact, the only documents they provided in the case file they submitted related to your costs are the EOC from this period that explicitly states that you have a $0 copayment for both primary care office visits and specialist office visits. The EOC also explicitly states you have a $0 cost share for an annual wellness visit. They provided no evidence to the contrary in the case file. The burden is on the Plan to show why their assessment of coinsurance was correct, and they have failed to do so in this case. Therefore, we decided that the Plan has to waive the coinsurance for office visits (99213) and an annual wellness visit (G0438) rendered from February 12, 2021, to May 26, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for urinalysis (81000) provided on June 23, 2020.  You asked the Plan to pay for urinalysis 81000. You say that the Plan's denial reason would not be correct. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 81000 has a procedure-to-procedure (PTP) edit of 1 with code 80305 so is not separately payable without an 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 urinalysis 81000 is a column II code to column I code 80305. 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 urinalysis (81000) provided on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the inpatient hospital services you received from May 28, 2021, to June 21, 2021.  You asked the Plan to reduce the copayment for the inpatient hospital services. You say that when you signed up for this plan, your agent told you that the inpatient copayment would only be $205 per day for 3 days, not for 6 days. The Plan denied your request. The Plan says you were charged this copayment 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 $295 copayment per day for days 1-6, and a $0 copayment per day for days 7-90 for inpatient hospital care.   Records show that you were in the hospital for 24 days.   You were charged a $295 copayment per day for the first 6 days, for a total of $1770. This copayment obligation is clearly laid out in your Evidence of Coverage. 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 reduce the copayment for the inpatient hospital services you received from May 28, 2021, to June 21, 2021.   Your complaint about information provided to you by the insurance sales agent 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for cystourethoscopy (52260-XU) provided on June 17, 2021.  You asked the Plan to pay for cystourethoscopy. You say that you billed this code correctly. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 52260 is inclusive to code 52214 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, the CPT Code Manual definition of code 52260-XU is cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia, the use of a service that is distinct because it does not overlap usual components of the main service.   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 cystourethoscopy. Our reviewer says that this code does not meet the Medicare criteria for payment. Our reviewer found the procedure report does not document that code 52260 is an unusual non-overlapping service from the covered code 52214; therefore, the -XU modifier 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 cystourethoscopy have not been met. Therefore, we decided that the Plan does not have to pay for cystourethoscopy (52260-XU) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you an additional amount for transplant related lodging and meals provided from May 12, 2021, through May 18, 2021.  You asked the Plan to reimburse you an additional amount for transplant related lodging and meals. The Plan denied your request. The Plan says according to the members benefits the member can be reimbursed for eligible lodging or places to stay costs up to $125 per day total. The member incurred accommodation charges of $1166.09 for 6 days from May 12, 2021, through May 17, 2021. The Plan will only pay up to $125 per day for accommodation charges, which for 6 days totals $750. The remainder of the charges for accommodation are not covered. The member also billed $423.91 for meals they had from May 12, 2021, through May 18, 2021. The Plan benefits say that charges for meals are not covered under any condition.  The Plan contract covers costs for lodging or places to stay such as hotels, motels or short-term housing as a result of travel for a covered organ transplant may also be covered. You can be reimbursed for eligible costs up to $125 per day total. We looked at the file and the Plan's rules. The file shows that the Plan reimbursed for you the benefit amount for eligible costs up to $125 per day total. The file also shows that charges for meals are not covered under any condition. Therefore, we decided that the Plan does not have to reimburse you an additional amount for transplant related lodging and meals provided from May 12, 2021, through May 18, 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 November 5, 2019, to November 13, 2019.  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 DRG was updated in this case.  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 despite presentation with an elevation in high-sensitivity troponin-T markers, the hospital record did not support reporting NSTEMI in this case. In this case, the Consulting Cardiologist indicated that serum troponin elevation was likely related to demand ischemia or acute coronary syndrome, rather than due to NSTEMI. There was an initial plan for cardiac catheterization articulated during initial telephonic consultation based on initial troponin elevation. However, once in-person consultation was completed, and demand ischemia deemed the likeliest explanation for troponin elevation, the decision was made to proceed without patient ischemia evaluation instead. Given the diagnostic considerations for "demand ischemia" and "acute coronary syndrome", rather than NSTEMI, the diagnosis code for NSTEMI was disallowed. Type 2 myocardial infarction and Other forms of acute ischemic heart disease are more appropriate diagnosis code. The review has determined that the records did not support that the correct DRG and diagnosis codes were used in this case.   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 November 5, 2019, to November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional resin-based composites and pulp cap provided on July 28, 2021.  You asked the Plan to pay for the additional resin-based composites and pulp cap. You say that you received no estimates from the dentist office, and you believed fillings were free. The Plan denied your request. The Plan says the annual maximum has been reached.  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 also have an annual maximum of $1,500 toward covered dental services. The Plan paid $1,500 toward the dental services provided from February 3, 2021, through July 28, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional resin-based composites and pulp cap provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on September 7, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the Plan covers hearing aids through the Plan's hearing aid provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient retina surgery you had on  July 23, 2021 at an ambulatory surgery center.  You asked the Plan to waive the copayment for the outpatient surgery. You say that you do not think you should have to pay this copayment.  You said that after the first surgery the retina of the same eye tore on the other side of the retina. The Plan denied your request. The Plan says you were charged this copayment 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 $100 copayment for outpatient surgery at an ambulatory surgery center.    You have been asked to pay a $100 copayment for the outpatient surgery. This copayment applies regardless of the reason for the surgery. 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 outpatient retina surgery you had on July 23, 2021 at an ambulatory surgery center.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical flap creation provided on September 23, 2020, billed with code 15734.  You asked the Plan to pay for the services as billed. You say that it is felt that the services were correctly billed and should be paid. The Plan denied your request. The Plan says the code is not supported in the record.  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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk.  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 as billed. Our reviewer says that the billed code is not supported. Our reviewer found the operative report does not include enough documentation to confirm the muscle was mobilized, elevated on its primary or secondary blood supply, and transferred, per National Correct Coding Initiative Policy Manual for Medicare Services. Therefore, 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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical flap creation provided on September 23, 2020, billed with code 15734.