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

We decided that the Plan does not have to pay for a hospital outpatient clinic visit.

You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says prior approval was not obtained for the services rendered.

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 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 a hospital outpatient clinic visit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 82607, 83970, 84100, 84443, and 85025.

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.

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 code 80053, 82607, 83970, 84100, 84443, and 85025 is not supported in the medical record. Specifically, the documentation does not include medical records. This means the documentation does not support how the enrollee came to the servicing provider or whether the services were medically necessary. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053, 82607, 83970, 84100, 84443, and 85025.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and X-rays.

You asked the Plan to waive the copayments for a specialist visit and X-rays. 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 specialist visits. Your contract with the Plan also clearly says that you must pay a $20 copayment per each X-ray.

You received a specialist visit. Therefore, you are responsible to pay the $40 copayment.

You received two X-rays. Therefore, you are responsible to pay a $20 copayment per each X-ray. The total amount you owe for X-rays is: $40.

The total amount you owe is: $80.

You have been asked to pay the total copayment amount of $80 for a specialist visit and X-rays. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for a specialist visit and X-rays.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on
September 22, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 a domiciliary, rest home visit provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services.

You asked the Plan to pay for the inpatient services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says the member's needs could have been safely met in a less restrictive setting.

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 inpatient services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member did not have dangerousness to self or others and was compliant with treatment. It did not appear that the services were reasonably expected to improve the member's condition or for the purpose of diagnosis beyond the date in question.

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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet rich plasma (PRP) injection (0232T).

You asked the Plan to pay for the PRP injection. You say that you are enclosing all documentation asked for. You are trying to avoid at least hip surgery. The Plan denied your request. The Plan says stem cell injections are only approved for certain diagnoses and conditions. Joint pain is not one of the diagnoses and conditions. Therefore, this service does not meet coverage criteria and is 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PRP injection have not been met. Therefore, we decided that the Plan does not have to pay for the platelet rich plasma (PRP) injection (0232T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99231).

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because this physician was acting as an interventionist on the billed date of service. The Plan denied your request. The Plan says the claim has not been billed showing that this was a separately identifiable service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99231 is not supported in the record. Specifically, the documentation submitted does not include sufficient information to determine if this was separately identifiable from the critical care services which were previously processed and paid. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain to metal crown.

You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain to metal crown. You say that you would like these services to be covered. The Plan denied your request. The Plan says these implant services are not covered benefits under your plan.

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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain to metal crown.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427 and A0425).

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because there were multiple trips on the same day. The Plan denied your request. The Plan says ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient admission and not separately billable.

The Plan must follow Medicare rules. Medicare rules say that if an ambulance is used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment the ambulance trip is considered part of the DRG, and not separately billable.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, payment for this service is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for ambulance services (A0427 and A0425).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the laboratory services. 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 laboratory services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested care is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested services are not medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of anterior segment aqueous drainage device,
without extraocular reservoir, internal approach, into the trabecular meshwork (CPT code 0191T), for the
enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee has already had this same procedure
done on the fellow eye with excellent results. The Plan denied your request. The Plan says the
request is not medically necessary because the enrollee's records show the enrollee is not being treated with a
medication to lower the pressure in their eye ("an ocular hypotensive medication").

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 services. Our physician reviewer
found the clinical documentation does not support that the enrollee is currently being treated with an ocular
hypotensive medication. 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 services have not been met. Therefore, we
decided that the Plan does not have to pre-approve insertion of anterior segment aqueous drainage device,
without extraocular reservoir, internal approach, into the trabecular meshwork (CPT code 0191T), for the
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed in the Medicare rules section.

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 lumbar-sacral orthosis. Our reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met.

The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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.

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 the laboratory services are not supported in the medical record. Specifically, these services should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told the hospital stay was fully covered. You say the enrollee has no ability to pay this amount. The Plan denied your request. The Plan says you have been asked to pay 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 $315 copayment per day for days 1-6 for each Medicare-covered hospital stay.

You have been asked to pay a $315 copayment for each day of the inpatient hospital stay. ($315 x 6 = $1,890). The inpatient 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274).

You asked the Plan to pay for the bitewing x-rays. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, bitewing x-rays (D0274) and are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7210) for tooth #'s 15 and 16.

You asked the Plan to pre-approve the extractions. You say that you would like the extractions to be approved for coverage for the enrollee. The Plan denied your request. The Plan says due to the significant bone loss and intact crowns, surgical extractions are not necessary.

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 extractions when the services are medically necessary and reasonable. 

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 extractions. Our reviewer says that the documentation does not indicate that surgical extractions (D7210) would be necessary for tooth #'s 15 and 16. Our physician reviewer found a surgical extraction is the extraction of an erupted tooth requiring removal of bone and/or sectioning of the tooth and including elevation of the mucoperiosteal flap if indicated. Our reviewer found that in this case the clinical crowns are intact and there is significant bone loss around the conical roots. Our physician reviewer also found that it appears that elevation and forceps removal would be adequate (D7140). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210) for tooth #'s 15 and 16.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office provided on October 20, 2020.

You asked the Plan to waive the copayment for the specialist office visit. You say that you saw your cardiologist for a wellness check. You say you would not have a copayment for any wellness check. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for each Medicare-covered specialist visit. 

You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows your provider is a cardiologist, who is considered a 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 specialist office visit provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99243) provided to the enrollee on February 13, 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 this is an invalid procedure code for this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99243 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 office visit services (CPT 99243) provided to the enrollee on February 13, 2020.