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

We decided that the Plan does not have to pay for extended patient service without direct patient contact 
(99358) provided on April 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for extended patient service without direct patient contact. You say that you would 
like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior 
authorization was not obtained before the services were rendered by an OON provider. 

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 extended patient service without direct patient 
contact (99358) provided on April 28, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies coded 95908, the needle electromyography coded 95885, and the unlisted neurological diagnostic procedure coded 95999 provided on January 12, 2021.
You asked the Plan to pay for the nerve conduction studies, the needle electromyography, and the unlisted neurological diagnostic procedure. 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.
We find that CPT codes 95908, 95885, and 95999 are not supported in the medical record. Specifically, the technical report did not include documentation of nerve conduction studies, for 3-4 studies; therefore, code 95908 cannot be verified. The technical report did not include documentation of a limited needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified. The technical report did not include documentation of an unlisted neurological or neuromuscular diagnostic procedure; therefore, code 95999 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies, the needle electromyography, and the unlisted neurological diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded 95908, the needle electromyography coded 95885, and the unlisted neurological diagnostic procedure coded 95999 provided on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on May 19, 2021.
You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed based on the medical records provided. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 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 of the head or brain (70450) provided on May 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities provided on October 28, 2019.
You asked the Plan to pay for the therapeutic activities. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the billed service is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
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 therapeutic activities. Our reviewer says that this does not meet criteria for coverage. Our reviewer found that the documentation submitted includes an occupational therapist evaluation which did not include therapeutic activities, direct one-on-one to support billing 4 units. Our reviewer says that the services were performed in the home and there is a more appropriate code to report for this service. 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 therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on January 6, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gluteus minimus tendon repair.

You asked the Plan to pre-approve gluteus minimus tendon repair. 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. 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 gluteus minimus tendon repair. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found surgery for repair is not indicated because the magnetic resonance imaging
(MRI) does not show severe tear of the tendon. Surgery is not needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of gluteus minimus tendon repair have not been met. Therefore, we decided that
the Plan does not have to pre-approve gluteus minimus tendon repair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services (procedure code 
99380) provided to the enrollee on March 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this has a status indicator of "B." 
 
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 99380 is "Supervision of a nursing facility patient 
(patient not present) requiring complex and multidisciplinary care modalities involving regular development 
and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related 
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care 
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) 
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment 
plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more." 
 
We find that CPT code 99380 is not supported in the medical record. Specifically, this code has a status 
indicator of "B" which means that payment for this code is always bundled into payment for other services. 
This code cannot be reported separately. 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 skilled 
nursing facility (SNF) services (procedure code 99380) provided to the enrollee on March 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 25, 2021, to April 12, 2021.
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment should be made for these services. The Plan denied your request. The Plan says the claim was Medicare payment was correctly denied.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital, the member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 25, 2021, to April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for TheraGraft applications (Q4121) provided October 26, 2020 
to November 23, 2020. 
 
You asked the Plan to pay for the TheraGraft applications. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this procedure is experimental and is not covered. 
 
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 pay for the TheraGraft applications. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the FDA has approved TheraSkin premarket approval for use in treatment of diabetic 
foot ulcers, venous stasis ulcers, and pressure ulcers. The clinical value and effectiveness of TheraSkin in the 
setting of a lower extremity wound following debridement of basal cell skin cancer have not been demonstrated 
in the peer reviewed literature. 
 
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 TheraGraft applications have not been met.

Therefore, we decided that the Plan does not have to pay for TheraGraft applications (Q4121) provided 
October 26, 2020 to November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided February 10, 2021.

You asked the Plan to pay for infrared therapy. You say that the enrollee was seen for acupuncture services.
According to the enrollee's benefit verification acupuncture is a covered benefit. Please see the attached
documentation and allow for coverage as services were medically necessary. The Plan denied your request. The
Plan says infrared therapy is considered not reasonable and necessary by Medicare and is excluded from
coverage.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for
infrared therapy (97026) provided February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on April 26, 2021.

You asked the Plan to pay for an office visit. You say that this was billed correctly. The Plan denied your request. The Plan says this should be billed with a bilateral code.

The Plan must follow Medicare rules. Medicare rules say that some International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

We looked at the file and Medicare rules. The service at issue was billed with two unilateral diagnosis codes, I70.201 and I70.202, but there is a more appropriate bilateral code to describe the enrollee's condition. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (26010) provided to the enrollee on October 15, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 26010 F6 (1 unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 26010 is "Drainage of finger abscess; simple." 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 services at issue in this case were not supported by the medical records. Our reviewer found the record does not indicated with a procedure note that the enrollee underwent the requested procedure. The elements of the billed code were not substantiated.
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 surgical services (26010) provided to the enrollee on October 15, 2020.
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 May 27, 2021.

You asked the Plan to pay for the comprehensive oral exam and intraoral x-rays. You say that you shouldn't have to pay anything. The Plan denied your request. The Plan says you have exceeded the frequency limit for the comprehensive oral exam and the intraoral x-rays are not covered under your 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. The Plan covers the comprehensive oral exam once every three years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on May 16, 2019.

Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the intraoral x-rays are not among those covered by the Plan. 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 May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the spine you had on June 16, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you are on a fixed income and you
cannot afford this. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for advanced imaging services (including MRIs).

You have been asked to pay a $175 copayment for the MRI. The MRI falls within the advanced imaging
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 the magnetic resonance
imaging (MRI) of the spine you had on June 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple (10061) provided January 10, 2021.
You asked the Plan to pay for the incision and drainage of abscess. You say that the services should be covered. The Plan denied your request. The Plan says billing code 10061 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate Current Procedural Terminology (CPT) code. 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 incision and drainage of abscess. Our reviewer says that the billing of incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple (10061) is not supported. Our reviewer found that documentation submitted shows the billed code does not meet criteria. The procedural report documents a simple incision and drainage was performed. A more appropriate code should be reported for documentation submitted. Therefore, this procedure is not covered.
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 incision and drainage of abscess have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple (10061) provided January 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) and a contact lens fitting (92310) provided on October 27, 2020, to March 16, 2021.
You asked the Plan to waive the copayment for an office visit and a contact lens fitting. You say that you did not request a contact lens exam. You say that you specifically told the provider on October 27, 2020 that you were only getting glasses. You also say you should not have to pay for a service you did not request. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $25 copayment for exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $25 copayment for an office visit. The EOC confirms that $25 is the required copayment for this 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 copayment for an office visit with a specialist (99213) and a contact lens fitting (92310) provided on October 27, 2020, to March 16, 2021.