Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the spine x-ray rendered on October 30, 2019.
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 72020 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 72020 is radiologic examination, spine, single view, specify level. We find that CPT code 72020 is not supported in the medical record. Specifically, there is no documentation of a single view x-ray of the spine. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the spine x-ray rendered on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 17, 2019 through November 19, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 17, 2019 through November 19, 2019.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 a home ventilator.
You asked the Plan to pre-approve a home ventilator (E0466). You say that the enrollee needs a home ventilator. The Plan denied your request. The Plan says the records show the enrollee has not tried a BiPAP at home.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator (E0466). Our reviewer says that the home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. The enrollee has severe COPD. The ventilator is prescribed to be used as a BiPAP device, which is not covered by Medicare. There are BiPAP devices that can provide the AVAPS-AE mode of ventilation, if necessary. There is no evidence of BiPAP failure. A home ventilator is not medically necessary and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator (E0466). have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 23, 2019.You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for services provided by a specialist. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient mental health stay provided from January 8, 2020 to January 16, 2020.
You asked the Plan to waive the copayment for an outpatient mental health stay. You say that you disagree with the charges because it was not your fault that in-network hospitals were not available. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $900 copayment per each stay for inpatient mental health care. You have been asked to pay a $900 copayment for an outpatient mental health stay. An outpatient mental health stay falls within the inpatient mental health 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 outpatient mental health stay provided from January 8, 2020 to January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray, Transportation of portable x-ray equipment, and set up of x-ray services provided on September 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe chest x-ray, Transportation of portable x-ray equipment, and set up of x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 onlyin 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 has network providers available who can provide 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 forthe chest x-ray, Transportation of portable x-rayequipment, and set up of x-ray services provided on September 25, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (CPT D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that you have several missing teeth and crowns after your provider completed extractions. You say that you have trouble eating, as food gets stuck in the places where teeth are missing. The Plan denied your request. The Plan says the benefit for dentures has 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the coverage for upper dentures is limited to once every 60 months. The records show that you received coverage for complete upper dentures in 2017. This means that your request for coverage of dentures in 2020 exceeds your benefit limitations. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (CPT D5110).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 9, 2019 by an out of network (OON) provider.
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 services were rendered by an out-of-network 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 has network providers available who can provide 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 medical services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray rendered on January 3, 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 services are not payable.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of
the PC of radiology services when furnished in a different payment locality than the TC.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 74018 with
modifier -26 for the PC and a place of service code 23 for emergency room. The file shows that the PC and TC
were not performed in different payment localities. Based on this information, we decided that Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
the abdomen x-ray rendered on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated Oral device/appliance (E0486).
You asked the Plan to pre-approve custom fabricated Oral device/appliance. You say that the use of this equipment is being recommended as part of his treatment for obstructive sleep apnea. The enrollee does not tolerate CPAP. The Plan denied your request. The Plan says the records do not support that the Medicare criteria has been established.
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 custom fabricated Oral device/appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the initial face to face clinical evaluation with diagnosis that led the enrollee to have the polysomnography as required in section (A).
Only criteria B, C and D appear to have been met. As all criteria have not been met, there is no medical necessity for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of custom fabricated Oral device/appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve custom fabricated Oral device/appliance (E0486).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of a interspinous and/or interlaminardevice (22869, 22870).You asked the Plan to pre-approveinsertion of a interspinous and/or interlaminar device. 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 insertion of a interspinous and/or interlaminar device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Ourphysician reviewer found the device is experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a interspinous and/or interlaminar device have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of a interspinous and/or interlaminar device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, five additional intraoral periapical x-rays, and maxillary immediate denture provided by an OON dentist on January 9, 2020.You asked the Plan to pay for the intraoral periapical x-rays and maxillary immediate denture. You say that you were not aware that this provider was not in-network. You also say that the provider never told you that they were not in-network anymore.The Plan denied your request. The Plan says services performed by an out-of-network provider are not covered because your healthcare plan does not have out-of-network benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, five additional intraoral periapical x-rays, and maxillary immediate denture provided by an OON dentist on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PCR testing provided on May 10, 2019.
You asked the Plan to pay for the PCR testing provided on May 10, 2019. You say that the provided PCR testing was medically necessary. The Plan denied your request. The Plan says the provided PCR testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the PCR testing provided on May 10, 2019. Our reviewer says that the provided PCR testing was not medically necessary. Our physician reviewer found the review indicates that the enrollee was with possible concern for urinary tract infection (UTI). She was having incontinence at night. She had a history of chronic kidney disease III and overactive bladder. On 5/28/19, a Physician visit showed the enrollee was recently treated for UTI no worrisome symptoms at this time. The provider sent a Urinary Tract Infection panel including antibiotic resistance markers utilizing PCR testing of urine on 5/10/19. The review has determined that the guidelines state that molecular diagnostic testing may be covered when the testing modality is approved through the MolDX process by Palmetto GBA. These tests must be assigned a unique test identifier. The standard of care is urinalysis with urine culture and sensitivity. The panel is not FDA approved. Using patient urine samples, polymerase chain reaction (PCR) assay was 94.4% sensitive and 99.9% specific for the diagnosis of schistosomiasis. PCR can detect and quantify schistosome deoxyribonucleic acid (DNA) in stool or urine. The review has determined that the PCR testing provided to the enrollee was not medically reasonable and 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 the PCR testing provided on May 10, 2019 have not been met. Therefore, we decided that the Plan does not have to pay for the PCR testing provided on May 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by code E0676.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a PCD coded E0676 is excluded from coverage. We looked at the file and Medicare rules. The item at issue is a PCD described by code E0676. This item is not a preventive services that is covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by code E0676.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the enrollee is receiving these services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute rehabilitation facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the trigger finger surgery provided on December 16, 2019.
You asked the Plan to waive the coinsurance for the trigger finger surgery. You submitted your bill for review. 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 30% coinsurance for each out-of-network Medicare-covered surgical service. You have been asked to pay $360.42 which is 30% of the allowed amount for the trigger finger surgery. The allowed amount is $1,201.38. ($1,201.38 x 30% = $360.42). The trigger finger surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 coinsurance for the trigger finger surgery provided on December 16, 2019.