Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for discharge day services provided by February 24, 2021.  You asked the Plan to pay for the services provided. You say that the documentation supports the codes are payable as billed. The Plan denied your request. The Plan says the billed service 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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not indicate the amount of time spent with the enrollee for the services at issue.   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 discharge day services provided by February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care at diagnosis related grouping (DRG) 459 provided from February 26, 2021, to March 7, 2021.  You asked the Plan to pay for inpatient care. You say that the record supports secondary diagnosis code J98.59. The Plan denied your request. The Plan says the denial of payment for this inpatient DRG is correct, because diagnosis code J98.59 is not supported so the Plan paid the claim at DRG 460 instead.  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 J98.59 other diseases of mediastinum, not otherwise classified. 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 inpatient care. Our reviewer says that this inpatient stay does not meet criteria for payment at the requested DRG 459. Our physician reviewer found the record does not include sufficient documentation to meet Medicare rules defining a comorbidity. Therefore, diagnosis code J98.59 does not meet criteria as a secondary diagnosis and DRG 459 is not payable.   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 care at diagnosis related grouping (DRG) 459 provided from February 26, 2021, to March 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on August 21, 2021.  

You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 the computed tomography (CT) scan (70450) provided on August 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 99053 provided on April 2, 2021.  

You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this is not eligible for payment.  

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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.  

We looked at the file and Medicare rules. Specifically, this code has a Status Code of "B" under the Physician Fee Schedule. Payment for these services are always bundled into payment for other services not specified. 

Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99053 provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to reimburse for the total difference between your cost share and the supplier's bill for the ostomy supplies. We decided that the Plan does not have to waive the deductible and coinsurance applied to the total supplier bill for the ostomy supplies.   You asked the Plan to reimburse additionally for the ostomy supplies. You say that you would like the Plan to reconsider your request. The Plan says that the claims for the ostomy supplies paid correctly.  We decided that the Plan has to reimburse additionally for the total difference between your cost-share and the supplier's bill for the ostomy supplies.   The rules say that for an MA-plan, non-contracting, non-participating DME supplier, the MAO must pay the non-contracting non-participating (non-par) DME supplier the difference between the enrollee's cost-sharing and the DME supplier's bill; the enrollee only pays plan-allowed cost-sharing. The coinsurance percentage is multiplied by the total provider bill if the MAO uses a coinsurance method for its cost-sharing. Note that the total provider bill may include permitted balance billing. Therefore, we decided that the Plan has reimburse for the total difference between your cost-share and the supplier's bill for the ostomy supplies.  We also decided that the Plan does not have to waive the deductible and coinsurance applied to the total supplier bill for the ostomy supplies.  In this case, the file shows that you purchased ostomy supplies from January 12, 2021 to September 16, 2021. You were asked to pay $100 towards your annual deductible. Once the deductible was met, you were asked to pay a 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the Durable medical equipment benefit category. This means you have been asked to pay the correct amount per your contract with the Plan. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance applied to the total supplier bill for the ostomy supplies.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on January 18, 2021.  You asked the Plan to pay for the services provided. You say that the claim was coded properly. The Plan denied your request. The Plan says no separate payment is made.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 99100 and 99140 are bundled codes. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on January 18, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the venipuncture (36410) and ultrasonic guidance for needle placement (76942) provided on March 31, 2021.  

You asked the Plan to pay for the venipuncture (36410) and ultrasonic guidance for needle placement (76942). You say that the services should not be bundled and classified as a non-payable charge. You say that the claim should be reprocessed according to the allowed rates. The Plan denied your request. The Plan says that a venipuncture is included in anesthesia and should not be separately reported. The Plan also says that the provider reported ultrasound guidance with anesthesia services which does not follow industry standard coding guidelines.  

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 forwarded any evidence that an anesthesia code was billed. The Plan has not substantiated their denial for why these services may not be paid. Therefore, we decided that the Plan has to pay for the venipuncture (36410) and ultrasonic guidance for needle placement (76942) provided on March 31, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an intraoral x-ray set (D0210) provided by a participating provider on September 23, 2021.  

You asked the Plan to pay for intraoral x-rays. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says the benefit limit for D0210 has already been exhausted.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers intraoral x-rays once per calendar year.   

We looked at the file, and Medicare rules. Evidence was provided to show that x-rays were provided on February 22, 2021. Based on this information, we decided that the Plan's rules for coverage of intraoral x-rays have already been exhausted. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray set (D0210) provided by a participating provider on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laser treatment (96920) provided on August 23, 2021.  

You asked the Plan to pay for code 96920. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

In this case, the CPT Code Manual definition of code 96920 is Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm.  

We find that CPT code 96920 is not supported in the medical record. Specifically, the records do not support that the code was used for reporting psoriasis treatment. Based on this information, we decided that Medicare rules for coverage of code 96920 have not been met. Therefore, we decided that the Plan does not have to pay for the laser treatment (96920) provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the paravertebral facet joint injection with image guidance (64493) provided on July 8, 2021.  You asked the Plan to pay for code 64493. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 64493 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 64493 have not been met. Therefore, we decided that the Plan does not have to pay for the paravertebral facet joint injection with image guidance (64493) provided on July 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services (G0299, G0151).  You asked the Plan to pre-approve the home health services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee's needs can be met at a lower level of care.  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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services (G0299, G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that your physician ordered this because wounds on your foot and from not having an arch. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 July 22, 2021.  

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were advised by the emergency medical services (EMS) that there was a 3-to-4-hour backlog at the hospital and that it would be better for you to stay in your recliner with an icepack on your ankle. The Plan denied your request. The Plan says the service in question is not covered under Medicare or the member's contract under any normal circumstances. Per Medicare guidelines, the ambulance benefit is a transport benefit. If there is no transport, then there is no Medicare-covered service.  

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 July 22, 2021. 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 July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) provided on August 18, 2021.  You asked the Plan to pay for the CT services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier was not billed with this service.  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 70450 is a column II code to column I code 70496. 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 the computed tomography (CT) of the head or brain (70450) provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous passive motion device to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are par providers available.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the device at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion device to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided September 9, 2021, to September 10, 2021.  

You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that you were never admitted to a room and left against medical advice because you were feeling fine. The Plan denied your request. The Plan says the copayment was applied correctly to the billed services. The Plan also notes that if the claim were processed as outpatient, your cost-share for the services provided would be greater.  

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 $360 copayment per day, days 1 to 5, for inpatient hospital care.  

You have been asked to pay a $360 copayment for the inpatient hospital admission and services. The inpatient hospital admission and services falls within the Inpatient hospital care 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 the inpatient hospital admission and services provided September 9, 2021, to September 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 8 additional outpatient physical therapy (PT) visits.  

You asked the Plan to pre-approve 8 additional PT visits. You say that requested additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the additional physical therapy visits are not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  

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 8 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation indicates that the enrollee has had prior therapy. The reviewer found the documentation does not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The reviewer found that the enrollee has been instructed in a home exercise program. The reviewer found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the additional PT visits are not medically necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional PT visits have not been met. Specifically, the file shows that the enrollee does not require the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Therefore, we decided that the Plan does not have to pre-approve 8 additional outpatient physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81302, 81406, 81407, and 81408 provided on May 21, 2021.  

You asked the Plan to pay for the laboratory 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 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.  

We find that CPT codes 81302, 81406, 81407, and 81408 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Review of the file does not support that only one code was billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81302, 81406, 81407, and 81408 provided on May 21, 2021.