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

 We decided that the Plan has to waive the copayment for the office visit (99213) provided on August 25, 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 that 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. Your contract with the Plan says that enrollees must pay $0 for a follow up visit following a discharge from a hospital, skilled nursing facility (SNF), Community Mental Health Center stay, outpatient observation, or partial hospitalization that meets the requirements as defined by Medicare.   The Plan says you must pay a $15 copayment for the specialist visit provided. Based on the Plan contract, however, you cannot be asked to pay more than $0 for a follow up visit following a discharge from a hospital. The record indicates that you previously received surgery from this provider on July 27, 2021; the service provided in this case was a follow-up visit for that procedure. Therefore, we decided that the Plan has to waive the copayment for the office visit (99213) provided on August 25, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced knee (L5828, L5845) and a flex foot system (L5981).

You asked the Plan to pre-approve an advanced knee and a flex foot system. You say that this is medically necessary. The Plan denied your request. The Plan says you are not a high-level walker.

The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828) is covered for beneficiaries whose functional level is 3 or above. A flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. Code L5845 is used for additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5828). 

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 an advanced knee and a flex foot system. Our reviewer says that the requirements for coverage of the requested items have not been met. Our physician reviewer found there is not clear and consistent documentation that your functional level is K3 or above. The medical records provided report that you still use crutches and a power scooter.

This is not consistent with a K3 functional level. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an advanced knee and a flex foot system have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced knee (L5828, L5845) and a flex foot system (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for initial hospital care services (procedure code 99233) provided to the enrollee on August 6, 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 the enrollee was in outpatient status at the time the services were rendered.  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 99223 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit."  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 based on the medical records provided, the documentation does not support the coding of the denied code as the place of service code on the claim conflicts with the hospital outpatient claim.   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 initial hospital care services (procedure code 99233) provided to the enrollee on August 6, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reimburse you $2,990 for office visits and chiropractic services. We decided that the Plan does not have to reimburse you $610 for office visits and chiropractic services.

You asked the Plan to reimburse you $3,600 for office visits and chiropractic services. You say that that you paid $3,600 to the chiropractor's office and you are requesting reimbursement. The Plan says that you received services on several dates. The Plan also says the claim was denied due to duplicate claims.

We decided that the Plan has to reimburse you $2,990 for office visits and chiropractic services.

The Plan follows Medicare rules. Medicare rules say that when a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.

We looked at your request, the file and Medicare rules. The record indicates that you were given a referral from a Plan provider to see this provider. The records show that you were given misinformation regarding the provider's network status, as verified by the Plan. The records also shows that you had an approved authorization to see this provider. You had fifteen (15) visits with the provider from May 17, 2021, to July 9, 2021. You must be held harmless and need not pay more than your contracted cost sharing amount of $20 per visit. Therefore, we decided that the Plan has to reimburse you $2,990 for office visits and chiropractic services.

We also decided that the Plan does not have to reimburse you $610 for office visits and chiropractic services.

The Plan follows Medicare rules. Medicare rules say that a health 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 $20 copayment for each Medicare covered chiropractic visit.

You have been asked to pay a $20 copayment for each chiropractic visit. The records show that you had 15 office visits with the provider and are responsible for a cost share amount of $300 ($20 x 15 visits = $300). The records also show that you received $310 from the provider's office towards your reimbursement for services. Therefore, we decided that the Plan does not have to reimburse you $610 for office visit sand chiropractic services.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 30, 2021 by an out-of-network (OON) provider.

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 payable.

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 laboratory services provided on July 30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing provided on July 29, 2021.  You asked the Plan to pay for the laboratory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare does not covered screening services.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97530) provided on May 27, 2021.

You asked the Plan to pay for occupational therapy services. You say that this was not available in-network.
The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct
supervision of auxiliary personnel.

We looked at the file and Medicare rules. The services at issue were provided by an occupational therapist and
billed as incident to a physician assistant's services, but the records do not show that the physician's assistant
was present for direct supervision. Based on this information, we decided that Medicare rules for coverage of
occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for
occupational therapy services (97530) provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99232) provided to the enrollee on July 12, 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 the evaluation and management procedure is included in the surgery procedure.  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 99232 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit."   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 documentation includes two "Provider Remittance Advice" for the same date of service and the same provider. There is Claim number KEN 03347835-00 CPT 99232, and Claim number KEN 03176640-00 CPT 93620 and CPT 33249. CPT 33249 is a major surgery, which allocates a 90-day global period in which the surgeon is responsible for all related surgical are one day before surgery through 90 postoperative days with no additional charge.  CPT 99232 was reported, was reviewed, and the record shows that this visit is related to CPT 33249, and should not be reported separately.  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 subsequent hospital care (procedure code 99232) provided to the enrollee on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the hip replacement surgery provided on March 8, 2021.  You asked the Plan to reimburse you for the hip replacement surgery. You say that you should be reimbursed as you overpaid for the surgery based on the Plan's contract. The Plan denied your request. The Plan says the reimbursement request is denied as you still owe the provider for two physical therapy visits provided on March 8, 2021, and March 9, 2021.  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 $325 copayment for Outpatient surgery and a $40 copayment for Outpatient rehabilitation services, specifically physical therapy services.    You have been asked to pay a $325 copayment for outpatient surgery and a $40 copayment for two physical therapy visits. The record indicates that you paid $350 towards your total cost-sharing, however, the provider is still expecting payment for the two physical therapy visits. Hip replacement surgeries and physical therapy services fall within the Outpatient surgery and 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 reimburse you for the hip replacement surgery provided on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for treatment of actinic keratoses provided on August 12, 2021.

You asked the Plan to waive the copayment for treatment of actinic keratoses. You say that you were not informed about the additional hospital cost that you were billed for the visit at issue and the charge should be removed from your balance. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Medicare-covered surgery or services. 

You have been asked to pay a $102.60 copayment for treatment of actinic keratoses.

Treatment of actinic keratoses falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay less than or equal to 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 treatment of actinic keratoses provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chiropractic care.  You asked the Plan to pre-approve chiropractic care. 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 follows Medicare rules. Medicare rules say that implementation of the chiropractic benefit requires an appreciation of the differences between chiropractic theory and experience and traditional medicine due to fundamental differences regarding etiology and theories of the pathogenesis of disease.  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 chiropractic care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the pain ratings do not demonstrate sustained improvement. The requested service is not medically reasonable or 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 chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic agent(s) and/or steroid injection (64450) provided on April 19, 2021.

You asked the Plan to pay for code 64450. 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 64450 is a column II code to column I code 01402. 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 anesthetic agent(s) and/or steroid injection (64450) provided on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve thirty-two (32) additional physical therapy (PT) visits (97139).  You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  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 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 enrollee has had instruction in a home exercise program. 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.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve thirty-two (32) additional physical therapy (PT) visits (97139).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 25, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you were not seen by a doctor after sitting for 6 hours. The Plan denied your request. The Plan says you have been charged 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 $90 copayment for each emergency care visit.   The record shows you were seen and diagnosed by the emergency room staff. Therefore, you have been asked to pay a $90 copayment for the emergency room visit. Emergency room visits fall within the Emergency 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 an emergency room visit provided on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services received on December 1, 2020.

You asked the Plan to pay for the anesthesia services. You say that you shouldn't have to pay anything. The Plan denied your request. The Plan says the services are not payable by the Plan.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.

However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has denied the claim for these services. In addition, we note that the provider is stating that these services were not workers compensation related. However, the documentation provided to the Plan only included the anesthesia records but the records do not note the reason for the surgery. The Plan has noted that if these services were not work-related they would accept the required records for reconsideration. Therefore, we decided that the Plan does not have to pay for the anesthesia services received on December 1, 2020.