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

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a nutrition specialist on February 23, 2021.

You asked the Plan to waive the copayment for the telehealth visit with a nutrition specialist. You say that you do not think it is fair to have to pay a copayment for a telehealth visit with a provider who is not your primary care doctor. 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 $45 copayment for telehealth visits with a specialist. 

You have been asked to pay a $45 copayment for the telehealth visit with a nutrition specialist. 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 telehealth visit you had with a nutrition specialist on February 23, 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 rendered on March 29, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the records received show that your 
condition has improved and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary in this 
case. It is not expected you would improve in a reasonable period of time as you are not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were 
compliant with treatment and having no side effects to the medication. It does not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond as you do not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our 
physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 
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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nasal/sinus endoscopy, surgical (31298) provided November 4, 2020.
You asked the Plan to pay for the surgical procedure. You say that please see attached supporting documentation for denied 31298-LT. Please review and reprocess. The Plan denied your request. The Plan says this service is not supported in the documentation provided.
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 31298-LT is a surgical nasal/sinus endoscopy, with dilation (balloon dilation), of the frontal and sphenoid sinus ostia. We find that CPT code 31298-LT is not supported in the medical record. Specifically, the operative report did not include documentation of a surgical nasal/sinus endoscopy, with dilation (balloon dilation), of the frontal and sphenoid sinus ostia. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for nasal/sinus endoscopy, surgical (31298) provided November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 7, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab work provided on March 29, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from August 26, 2020, through August 31, 2020 with the reported principal diagnosis A41.9, Sepsis, unspecified organism.

You asked the Plan to pay for inpatient services provided from August 26, 2020, through August 31, 2020 with the reported principal diagnosis A41.9, Sepsis, unspecified organism. The Plan denied your request. The Plan says based upon the Uniform Hospital Discharge Data Set rules, the corrected DRG 981 is more accurate. The primary diagnosis was J18.9, Pneumonia, unspecified organism, rather than Sepsis.

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 the reported principal diagnosis A41.9, Sepsis, unspecified organism. We asked our coding 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 services provided from August 26, 2020, through August 31, 2020 with the reported principal diagnosis A41.9, Sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our coding reviewer found the medical records submitted support J18.9 - Pneumonia as the primary diagnosis for billed services from August 26, 2020 through August 31, 2020. Therefore, the appropriate DRG associated would be 981, not submitted DRG 853.

We looked at this coding 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 services provided from August 26, 2020, through August 31, 2020 with the reported principal diagnosis A41.9, Sepsis, unspecified organism.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the myelography procedure via lumbar injection and computed tomography (CT) scan of the lumbar spine you had on January 8, 2021.
You asked the Plan to waive the copayments for the myelography procedure and CT scan. You say that the billing was done incorrectly for these services. The Plan denied your request. The Plan says that you were charged these copayments 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 $225 copayment for outpatient hospital services and a $225 copayment for diagnostic radiology services.
Records show that on this date of service, you had both a myelogram via lumbar injection and you had a CT scan. You have been asked to pay a $225 copayment for each of these services. The myelogram via lumbar injection is a medical service you received at an outpatient hospital facility. The CT scan is a diagnostic radiology service. These are separate and distinct services for which individual cost sharing is owed. Your Evidence of Coverage clearly states that if you receive other services while you are at an outpatient hospital facility that additional cost sharing may apply. 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 copayments for the myelography procedure via lumbar injection and computed tomography (CT) scan of the lumbar spine you had on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on April 14, 2021.
You asked the Plan to pay for the 2D oral or facial photographic image. You say that you were not told that your regular dentist was no longer practicing at that office. You also say that you feel the services should be covered. The Plan denied your request. The Plan says 2D oral or facial photographic image is not listed as a covered service.
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 2D oral or facial photographic image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on April 14, 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 rendered on May 7, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional PT visits.

You asked the Plan to pre-approve twenty-four (24) additional PT visits. The Plan denied your request. The Plan says additional physical therapy visits does not meet CMS medical necessity 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 twenty-four (24) 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had extensive prior therapy and the records do 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 enrollee has been instructed 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 twenty-four (24) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from December
28, 2020, to December 31, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told your
wearable defibrillator would be paid for by Medicare and you cannot afford the cost of the services related to it.
The Plan denied your request. The Plan says the copayment for the hospital stay has been 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 $300
copayment per day for days 1-5 for inpatient hospital care.

You have been asked to pay a total of $900 ($300 copayment x 3 days = $900) for the inpatient hospital stay.
This hospital stay 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 stay from December 28, 2020, to December 31, 2020.

Your complaint about potentially being provided incorrect or incomplete information about coverage by a
provider or plan representative is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision testing (0379T--Visual Field Assessment) for the enrollee.

You asked the Plan to pre-approve this service. You say that this testing is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules specifically state this is a non-covered service. Therefore, we decided that the Plan does not have to pre-approve vision testing (0379T--Visual Field Assessment) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that while you may benefit from continuing physical, occupational, and speech therapy, the records do not support the need for daily therapy on an inpatient basis.
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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on April 2, 2021, billed with code 76700-26.
You asked the Plan to pay for the ultrasound interpretation as billed. You say that multiple exams were provided on this date of service and should all be paid. The Plan denied your request. The Plan says this code was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that NCCI edits with a modifier indicator of 1 denote code pairs which cannot be reported together without a clinically appropriate modifier.
In this case, code 76700 is a Column 2 code in relation to code 93976, which was paid on this claim. Without a clinically appropriate modifier on the Column 2 code, it cannot be separately paid. Therefore, we decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on April 2, 2021, billed with code 76700-26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms which would require acute treatment. You were described as having an improved disorganized thought process. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others but were compliant with your treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF provided from February 14, 2021, through March 15, 2021. You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continued SNF care is not medically necessary.
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 medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received enteral nutrition and medications. The enrollee had stable vital signs. The enrollee was monitored for left buttocks wound. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a maximal assist to dependent level with bed mobility and transfers. The enrollee required varying assist with activities of daily living. There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF services provided from February 14, 2021, through March 15, 2021.