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

We decided that the Plan does not have to pay for the noninvasive ear or pulse oximetry for oxygen saturation (94760) provided on October 2, 2020.

You asked the Plan to pay for the noninvasive ear or pulse oximetry. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that the ambulance must have customary patient care equipment and first aid supplies which are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the noninvasive ear or pulse oximetry have not been met. Therefore, we decided that the Plan does not have to pay for the noninvasive ear or pulse oximetry for oxygen saturation (94760) provided on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 22, 2021.
You asked the Plan to pay for the dental services. You say that you were never informed that your dentist was not in network. You also say that you received a bill for the services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network 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, dental services received out of network are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical surgical supplies provided on May 18, 2021.

You asked the Plan to waive the coinsurance for the medical surgical supplies. You say that the medical surgery supplies should be considered a part of your surgery and not a separate charge. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each in-network Medicare-covered medical supply. 

You have been asked to pay $252.01 which is 20% of the allowed amount for the medical surgical supplies. The allowed amount is $1,260.04. ($1,260.04 x 20% = $252.01). The medical surgical supplies fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the medical surgical supplies are considered a separate service.

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 medical surgical supplies provided on May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. 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 a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found this is a clinical trial. Thus experimental/investigational and not compendia supported. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on July 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 x-ray services provided on July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A425) provided on June 24, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found that the enrollee was transported from a hospital to skilled nursing facility (SNF). The enrollee has chronic obstructive pulmonary disease and obesity. He was found to require 4 liters of oxygen supplementation and did not have his own portable oxygen tank. He was able to stand and pivot to the cot prior to transfer via stretcher. His vitals were stable. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport. Oxygen could have been provided via other means of transport and the enrollee was stable and didn't receive any other treatment during transport. The documentation does not support that the ambulance transport on June 24, 2021 was medically reasonable and necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A425) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 31, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you should not have been charged a copayment because this was your annual wellness visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for provider and professional services for an in-network primary care physician's office. 

You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows diagnosis codes for gastroesophageal reflux, Hodgkin lymphoma, and lipoprotein metabolism disorders which is considered separate from the annual wellness visit.

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 office visit provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary visit provided on July 14, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and you did not know that the facility failed to get prior authorization. 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 domiciliary visit provided on July 14, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid coded 87798 provided on July 13, 2021.

You asked the Plan to pay for infectious agent detection by nucleic acid. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.

We find that CPT code 87798 is not supported in the medical record. Specifically, this service was billed with modifier 91. This modifier may not be used when tests are rerun to confirm initial results, or due to testing problems with specimens or equipment. Modifier 91 may only be used for laboratory test(s) performed more than once on the same date on the same enrollee. Review of the documentation does not support the correct billing of modifier 91 for these services. Based on this information, we decided that Medicare rules for coverage of infectious agent detection by nucleic acid have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid coded 87798 provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided April 30, 2019, and the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided August 16, 2019.
You asked the Plan to pay for the comprehensive oral exam, intraoral x-rays, complete upper denture and complete lower denture. You say that your claim was filed late due to the pandemic time of isolation. You also say that you were not able to get anyone at the clinic to get you the documents, and you would like to be partially reimbursed for these services. The Plan denied your request. The Plan says this claim was received on August 3, 2021, which is past the allowed 12-month 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 comprehensive oral exam, intraoral x-rays, complete upper denture and complete lower denture was not filed until August 3, 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 comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided April 30, 2019, and the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation services provided from August 10, 2021, to August 11, 2021.

You asked the Plan to pay for the services provided. You say that the physician deemed it necessary for the enrollee to undergo treatment. The Plan denied your request. The Plan says the observation code is not allowed to be reported more than once per claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

In this case, the CPT Code Manual definition of code G0378 is hospital observation service, per hour. We find that CPT code G0378 was billed two times on the claim at issue. We looked at the file and the rules. If a period of observation spans more than 1 calendar day, all of the hours for the entire period of observation must be included on a single line and the date of service for that line is the date that observation care begins.

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 observation services provided from August 10, 2021, to August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation device used for cancer treatment (E0766) provided on July 15, 2021.

You asked the Plan to pay for the electrical stimulation device. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that that tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of recurrent GBM. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation device have not been met. Specifically, the record indicates that this service is being requested for the treatment of recurrent GBM. Therefore, we decided that the Plan does not have to pay for the electrical stimulation device used for cancer treatment (E0766) provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87496, 87511, 87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798) provided on February 3, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code.
We looked at the file and Medicare rules. The only diagnosis billed on the claim, N39.0, has a "use additional code" note, but there was not an additional code billed. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87496, 87511, 87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798) provided on February 3, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy (97026) provided on August 5, 2021.

You asked the Plan to pay for the infrared therapy. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral complete series of radiographic images (D0210) provided on September 27, 2021.

You asked the Plan to pay for a comprehensive oral evaluation and an intraoral complete series of radiographic images. You say that you have been seeing the same dentist for the last couple of years. You also say this is the first time going to the dentist since the pandemic began and you are requesting the treatment for your teeth be paid in full. The Plan denied your request. The Plan says the requested services exceed the maximum allowed per period.

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. The Plan covers a comprehensive oral evaluation and an intraoral complete series of radiographic images once every 3 plan years.

We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation and an intraoral complete series of radiographic images on September 12, 2019, therefore, you have exhausted your maximum benefit for these services. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and an intraoral complete series of radiographic images have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral complete series of radiographic images (D0210) provided on September 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on June 22,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and related 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 office visit and related services provided on
June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 854 provided from July 1, 2020 to July 11, 2020.

You asked the Plan to pay for the inpatient hospital services with DRG 854. You say that the medical records support the billing of the principal diagnosis code A41.9 with DRG 854. The Plan denied your request. The Plan says the medical records do not support the billing of the principal diagnosis code A41.9 with DRG 854.

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. 

In this case, you billed the inpatient services provided with A41.9. 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 inpatient hospital services with DRG 854. Our reviewer says that the medical records do not support the billing of the principal diagnosis code A41.9 with DRG 854. Our physician reviewer found the review indicates that the documentation supported an admission for pyelonephritis. The documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though sepsis is documented throughout the medical record, supporting medical record documentation was not found within the record. The 32-y/o female presented to the emergency department (ED) with complaints of fever and groin pain. Patient treatment included IV fluids/antibiotics. The appeal letter indicated Sepsis 2 or Systemic Inflammatory Response Syndrome (SIRS) criteria had been met, based on fever, leukocytosis, tachycardia, and tachypnea. SIRS criteria and procalcitonin levels are often recommended and utilized as screening tools; however, these tools are not utilized as a reliable diagnostic indicator for sepsis. There was no documentation of sepsis provided. The review has determined that the medical records did not support the billing of the principal diagnosis code A41.9 with DRG 854. 

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 the inpatient hospital services with diagnosis related group (DRG) 854 provided from July 1, 2020 to July 11, 2020.