Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health services.

You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your
request. The Plan says continued therapy can be safely transitioned to a home exercise program and does not
require the services of a trained therapy professional. The Plan states continued skilled nursing visits are not
medically necessary as the care can be safely transitioned to a trained caregiver.

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 visits. Our physician reviewer found
based on the medical records provided there is no documentation that skilled nursing services are required to
effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a
maintenance program to maintain your condition and/or prevent deterioration. The provided records do not
document any unstable medical conditions requiring skilled nursing services. There is no documentation that
skilled physical therapy services are required to effectively provide treatment, care, and/or services in order to
improve your level of function, or to establish/perform a maintenance program to maintain your level of
function and/or prevent deterioration. The enrollee is walking 250 feet with a rolling walker and negotiating
stairs with minimal contact assistance.

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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 7, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit (99204). You say that you are a contract provider so the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization as required.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these service. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 7, 2021 by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from February 1, 2021, through February 19, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you were assured by the person at the reception desk that you would nothing. You say that you would not have used therapy if you knew there was a copayment and the decision should be favorable. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit.
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $360 ($40/visit x 9 visits = $360). Physical therapy falls within the "Outpatient Rehabilitation Services" 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 physical therapy provided from February 1, 2021, through February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel surgery for the right thumb.
You asked the Plan to pre-approve the surgery. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. In addition, there are no diagnostic studies provided for review to fully corroborate pathology of either carpal tunnel syndrome (or right trigger thumb.) There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel surgery for the right thumb.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for severing adhesions of anterior segment of eye coded 65875 provided on December 1, 2020.
You asked the Plan to pay for severing adhesions of anterior segment of eye. 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 separately payable.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, there is a Correct Coding Initiative conflict between codes 65875 and 66982 (extracapsular cataract removal) also billed on the claim. The documentation does not support that the service was distinct or independent from other services performed. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for severing adhesions of anterior segment of eye coded 65875 provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cast cover (A9270) provided on July 29, 2020.
You asked the Plan to pay for a cast cover. You say that the requested item was essential after your surgery. You are on a fixed income and the charge is major for you. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a cast cover (A9270) provided on July 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on June 18, 2020.

You asked the Plan to pay for the emergency department visit. 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 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 99284 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components: A detailed history; A detailed
examination; and Medical decision making of moderate 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 require urgent evaluation by the physician, or other
qualified health care professionals but do not pose an immediate significant threat to life or physiologic
function.

We find that CPT code 99284 is not supported in the medical record. Specifically, this code was billed with
diagnosis codes D53.9 (nutritional anemia, unspecified.) and D64.9 (anemia, unspecified). These two diagnosis
codes should not be billed together. Based on this information, we decided that Medicare rules for coverage of
the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for
the emergency department visit provided on June 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64708, 27339) provided on November 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 27339 is "Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greater". 

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 codes 64708 and 27339 is not supported by the records provided. Our reviewer found that CPT 64708 would not be covered separately, as it is inclusive to CPT 27310. Surgical approach, including identification of anatomical landmarks, incision, evaluation of surgical field, debridement of traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring are considered integral to the primary service. For CPT 27339, an excision tumor soft tissue of thigh or knee area is not documented in the operative report, and therefore 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 have not been met. Therefore, we decided that the Plan does not have to pay for the services (64708, 27339) provided on November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins when required (D2950) provided on May 10, 2021.

You asked the Plan to pay for the crown and core buildup. You say that you are on a fixed income, and you have found out that none of the options you were offered are covered under your plan. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to having these services rendered to verify benefits and provider eligibility.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins when required (D2950) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on February 16, 2021.

You asked the Plan to pay for these services. You say that this service should be covered by the Plan. 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 February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, shoulder (73030) and radiologic examination, knee (73564) provided March 26, 2021 to April 9, 2021.

You asked the Plan to waive the copayment for the diagnostic x-ray services. You say that it was not known, nor were you made aware that there would be a copay for diagnostic services until after the services was provided at a facility that is listed as an in-network facility/provider. The Plan denied your request. The Plan says the claims were processed with the correct copayments applied per the Evidence of Coverage.

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 $100 copayment for basic radiological services in an outpatient hospital. for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay $185.49 (85.49 + $100) copayment for the diagnostic x-ray services. The allowed amount for 3/26/2021 date of service was $85.49. Since the allowed amount for this date of service is less than the copay amount, you are responsible for the lower amount. The diagnostic x-ray services fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 radiologic examination, shoulder (73030) and radiologic examination, knee (73564) provided March 26, 2021 to April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colposcopy of the vagina (57420) provided on March 23, 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 a $150 copayment for Medicare-covered outpatient hospital surgery services. You have been asked to pay a $150 copayment for the Medicare-covered outpatient hospital surgical service 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 copayment for the colposcopy of the vagina (57420) provided on March 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed tomography (CT) scan coded 70450 provided on February 13, 2021.

You asked the Plan to pay for the CT scan. 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 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, we have confirmed that code the CT scan has a bundled relationship with code 70450 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 (CT) scan coded 70450 provided on February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic and retainer crown for a fixed bridge provided on March 10, 2021.
You asked the Plan to pay for the pontic and retainer crown. You say that you are requesting to appeal the dental claim. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic and retainer crown for a fixed bridge provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit and cup holder (CPT code(s): A9270 and K0108).
You asked the Plan to pre-approve the items. You say that you need to get the wheelchair as soon as possible so you can get around and your current wheelchair is very dangerous. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Durable medical equipment is covered if it is appropriate for use in your home. The transit kit is used to strap the wheelchair to a vehicle to travel outside the home. The denial is correct. A cup holder does not serve a medical purpose. It is for your convenience. Therefore, we decided that the Plan does not have to pre-approve a transit kit and cup holder (CPT code(s): A9270 and K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee arthroscopy services coded 29879 provided on May 3, 2019.
You asked the Plan to pay for the knee arthroscopy 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 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 29879 is arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture. We find that CPT code 29879 is not supported in the medical record. Specifically, this code was billed with modifier LT (left). There is no supporting documentation submitted to establish the performance of this code.
Based on this information, we decided that Medicare rules for coverage of the knee arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the knee arthroscopy services coded 29879 provided on May 3, 2019.