Persius/hicric huggingface dataset:
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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. Our physician reviewer found the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from May 6, 2021, to May 21, 2021.
You asked the Plan to waive the copayment for inpatient care. You say that you feel this hospital stay was only necessary because you were discharged from the hospital in March while you were still sick. You feel this inpatient admission could have been prevented, and you should not be responsible for this cost. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $350 copayment for each of the first five days of an inpatient hospital stay.
There is a $0 copayment for additional days. You have been asked to pay a $1,750 copayment for an inpatient hospital stay which exceeded five days ($350 x 5 days = $1,750). 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 inpatient hospital services provided from May 6, 2021, to May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services coded 75710 and the revascularization services coded 37232 provided on March 31, 2021.

You asked the Plan to pay for the angiography services and the revascularization 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, we have confirmed that code 75710 for the angiography services is a column II code to column I code 37227. 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.

We find that CPT code 37232 is not supported in the medical record. Specifically, the operative report did not include documentation of an open or percutaneous endovascular revascularization, of unilateral tibial/peroneal artery, for each additional vessel, with transluminal angioplasty (listed separately in addition to code for primary procedure); therefore, code 37232 cannot be verified.

Therefore, we decided that the Plan does not have to pay for the angiography services coded 75710 and the revascularization services coded 37232 provided on March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection, of a small joint or bursa, with ultrasound guidance (20604) provided on June 9, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 $0 for Medicare-covered colonoscopies. Additionally, enrollees pay $100 per day for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. 

You have been asked to pay a $100 copayment for the outpatient surgery provided in an outpatient hospital. 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 arthrocentesis, aspiration and/or injection, of a small joint or bursa, with ultrasound guidance (20604) provided on June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper endoscopy with biopsy (43239) provided on June 16, 2021.

You asked the Plan to waive the copayment for the endoscopy procedure. You say that this service should have no copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 $250 copayment for outpatient procedures and services, including but not limited to, diagnostic and therapeutic endoscopy and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.

You have been asked to pay a $250 copayment for the endoscopy procedure. 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 upper endoscopy with biopsy (43239) provided on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the nuclear cardiac imaging you received at an outpatient hospital facility on July 26, 2021.

You asked the Plan to waive the cost sharing for the nuclear cardiac imaging. You say that you should not have to pay a copayment for services recommended by your doctor. You say that you pay enough for insurance, and you should not have to pay copayments for any services other than doctor office visits. 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 20% coinsurance, up to $75 for nuclear cardiac imaging. 

You have been asked to pay $75 for the nuclear cardiac imaging. 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 the nuclear cardiac imaging you received at an outpatient hospital facility on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on January 22, 2020.

You asked the Plan to pay for the services provided. You say that the billing company did not file the claims in a timely manner. The Plan denied your request. The Plan says the claim was received past the allowed timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services provided was not filed until June 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on January 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance provided on April 29, 2021.
You asked the Plan to pay for the services provided. You say that separate procedures were performed. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 77001 was billed with 77012. CPT Code 77001 may be eligible for payment when billed with this code pair. The claim provided does not indicate the code was billed with a modifier suitable for payment. 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 fluoroscopic guidance provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiology visits you had on May 13, 2021, and July 17, 2021.

You asked the Plan to waive the copayments for the cardiology visits. You say that this was related to post-COVID symptoms, so the copayment should be waived. The Plan denied your request. The Plan says there was no copayment waiver in effect at the time of these services.

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 $45 copayment for specialist services. 

You have been asked to pay a $45 copayment for each of the cardiology visits. Please note that the Plan's website explicitly states that the Plan is not waiving cost sharing for COVID-19 treatment. The website states that you will be responsible for cost sharing according to your benefit plan for COVID-19 treatment. 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 copayments for the cardiology visits you had on May 13, 2021, and July 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine electrocardiogram services (93005) provided on May 31, 2021.
You asked the Plan to pay for the routine electrocardiogram services. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says payment for the services billed is packed into another payment for other services.
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 93005 is electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report. We find that separate payment for CPT code 93005 is not supported based on Medicare rules. Specifically, under the Hospital Outpatient Prospective Payment System this code has a Payment Status Indicator of Q1. This status indicator indicates that if the code is billed on the same claim as a Healthcare Common Procedure
Coding System (HCPCS) assigned a status indicator of "S", "T", or "V" the Ambulatory Payment Classifications (APC) will be packaged, and no separate payment will be made for this service. In this case, code 99285 has been billed on this claim which has a status indicator "V". Therefore, payment for 93005 will be bundled into the APC for 99285. Based on this information, we decided that Medicare rules for coverage of the routine electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for the routine electrocardiogram services (93005) provided on May 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the abdomen (74183) and Gadobutrol injection (A9585) provided on June 19, 2021.
You asked the Plan to pay for the MRI and Gadobutrol injection. You say that the enrollee was not in hospice at the time of these 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 enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on June 18, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the abdomen (74183) and Gadobutrol injection (A9585) provided on June 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 27, 2021.

You asked the Plan to pay for lab tests. You say that this diagnosis code supports medical necessity. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is not covered for screening purposes.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Without an order, it cannot be determined whether this testing was requested for Medicare-covered purposes. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 7, 2020.

You asked the Plan to pay for lab test. You say that you were not provided with the correct diagnosis codes until after the timely filing limit expired. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this claim was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for lab test was not filed until August 6, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (22854, 63082) provided April 6, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 22854 & 63082 are not supported in the medical record. Specifically, the medical records provided do not include sufficient documentation to validate that an insertion of intervertebral biomechanical device or vertebral corpectomy was performed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (22854, 63082) provided April 6, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 9,
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 an appropriate modifier was not 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.
We find that CPT code 70450 was billed with code 70496. 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 July 9, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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. Our physician reviewer found the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with an orthopedic surgeon at an outpatient hospital on June 21, 2021.
You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that an office visit did not occur. You said that the enrollee was admitted so there should be no copayment. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan confirmed that the patient was not an inpatient in the hospital on the date of service, so the specialist copayment applies. The Plan confirmed that the patient was in observation status (which is not an inpatient admission) at the time of this visit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for specialist services in an outpatient hospital setting. The enrollee has been asked to pay a $35 copayment for the orthopedic surgery visit. The orthopedic surgery visit falls within the specialist services in an outpatient hospital setting benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the visit with an orthopedic surgeon at an outpatient hospital on June 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and continuation.

You asked the Plan to pre-approve the SNF admission and continuation. The Plan denied your request. The Plan says the medical records do not support that the enrollee has any skilled needs (need for care or treatment) identified at this time and no acute medical issues were identified. The Plan also says that the required needs are custodial in nature and can be met at a lower level of care.

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 the SNF admission and continuation. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission and continuation have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and continuation.