Persius/hicric huggingface dataset:
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 an LTACH would better meet your care needs The Plan denied your request. The Plan says you likely do not require hospital-level care for 25 days or more. LTACHs also do not provide a clinical advantage over a non-LTACH acute care hospital. Therefore, a transfer to an LTACH is not medically necessary in this case. Once you are ready to leave the hospital, the necessary services can be provided at a lower level of care.

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 there is no documentation provided demonstrating medical necessity for LTACH services. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available and covered at the acute care hospital where you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional unit of Current Procedural Terminology (CPT) 86077 provided to the enrollee on August 25, 2020.

You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your request. The Plan says one unit remains not payable as the allowed amount per day is one.

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 is "Blood bank physician's services; difficult cross match and/or evaluation of irregular antibody(s), interpretation and written report." 

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 the additional unit. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found per Medicare guidelines, 86077 has a 1 unit per day MUE allowance, therefore, only 1 unit of 86077 would be payable.

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 additional unit have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of Current Procedural Terminology (CPT) 86077 provided to the enrollee on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided February 15, 2021.

You asked the Plan to pay for the dental cleaning. You say that you were told you would be reimbursed. The Plan denied your request. The Plan says because the service was provided out-of-network, it is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental cleaning when the services are provided in-network. 

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided February 15, 2021.

Your complaint about receiving conflicting and confusing information about reimbursement after the services were provided 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan of the heart for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is needed for further evaluation of an abnormal electrocardiogram (ECG) done prior to spinal surgery. The Plan denied your request. The Plan says that research studies have found a lack of evidence that routine use of this study would improve the outcome for your type of condition.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the planned spinal surgery is risky for an enrollee with significant cardiac dysfunction. It is very reasonable to proceed with a PET/CT in an enrollee with multiple documented myocardial infarcts in order to assess the degree of myocardial viability. 

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 scan have been met. Therefore, we decided that the Plan has to pre-approve a PET/CT scan of the heart for the enrollee.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on August 13, 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 procedure code 64999 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 64999 is unlisted procedure, nervous system. 

We find that CPT code 64999 is not supported in the medical record. Specifically, a complete description of the unlisted code was not submitted. 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 services rendered on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid check (92593) provided on March 11, 2021.

You asked the Plan to pay for a hearing aid check. You say that the provider could not work with your hearing aid and told you that you would need to buy a new one they could work with. The Plan denied your request. The Plan says the service at issue was rendered by a non-participating provider and is not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a hearing aid check have not been met. Specifically, the service at issue was rendered by an out-of-network vendor and is not covered. Therefore, we decided that the Plan does not have to pay for a hearing aid check (92593) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing home visit services (99336, 99337) provided on June
17, 2020, to August 26, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for nursing home visit services. You say that you would like these claims
reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not
obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for nursing home visit services (99336, 99337)
provided on June 17, 2020, to August 26, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on March 3, 2021.

You asked the Plan to pay for the self-administered drug. You say that you had no procedures, services or medications that were not doctor ordered and medically necessary. The Plan denied your request. The Plan says these drugs may be covered under the Part D benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug provided on March 3, 2021.

Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on October 8, 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 procedure code 99152 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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status. 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 moderate sedation services rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on March 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the physician visit services denied because the benefit for this service is
included in the payment or allowance for another service or procedure that has already been adjudicated.
Pre/Post-operative care payment is included in the allowance for the surgery or procedure. The Plan further
states code 99214-25 denied due to being bundled as part of the global surgical fee because it was reported
within global period of the major surgical procedure that was billed under a separate claim for date of service
March 4, 2021 by same provider. Per Medicare Claims Processing Manual, Chapter 12, section 40.1, A, postoperative
visits performed during the postoperative period of a global surgery that are related to the recovery
from that surgery are included in the global surgical package. In addition, 40.2, A, section 7 states that a
physician may need to indicate that the performance of a procedure or service during a postoperative period
was unrelated to the original procedure by appending an appropriate modifier.
Review of medical record indicates that the service performed was unrelated to the major procedure
performed on March 11, 2021. The records show the enrollee returned for follow up for a left axillary
epidermal cyst infection, complaints of fatigue and gland pain in the left side of the, which indicates
this was a complication from the previous procedure. However, this code was not billed with a modifier to
represent a complication. Therefore, the Plan upheld code 99214-25 as the required billing criteria were not
met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to the
bundled relationship between codes and the lack of an appropriate modifier to show this was treatment due to
complication of the prior service. Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on March 11,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection rendered on May 15, 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 procedure code S0020 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code S0020 (bupivicaine hydrochloride injection) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the bupivicaine hydrochloride injection rendered on May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit for a new patient (99204), the
partial removal of an implant (D9999 x 2), the osseous graft (D7950), the analgesia (D9230), and the
panoramic x-ray (D0330) provided from July 14, 2020, to July 29, 2020.

You asked the Plan to reimburse you for the dental services. You say that the services should be covered. You
also say that payment should be sent to you because you already paid for them. The Plan denied your request.
The Plan says the provider in this case is out of network. The Plan says that services performed out of network
are not covered. The Plan also says you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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, dental services performed out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
reimburse you for the office visit for a new patient (99204), the partial removal of an implant (D9999 x 2), the
osseous graft (D7950), the analgesia (D9230), and the panoramic x-ray (D0330) provided from July 14, 2020,
to July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two problem focused limited oral evaluations (D0140 x2), cone beam computed tomography (CT) capture and interpretation (D0364), and bone replacement graft for ridge preservation (D7953) provided from March 8, 2021, to March 22, 2021.

You asked the Plan to pay for the problem focused limited oral evaluations, cone beam CT capture and interpretation, and bone replacement graft. You say that you think that the bone graft should be covered. The Plan denied your request. The Plan says these services are not covered dental benefits. The Plan also says that the provider's office was able to provide a pay agreement you signed verifying that you understand that you are financially responsible for payments in full of all accounts and agree to be responsible for payment of services not paid, in whole or in part by your dental care payor.

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 two problem focused limited oral evaluations (D0140 x2), cone beam computed tomography (CT) capture and interpretation (D0364), and bone replacement graft for ridge preservation (D7953) provided from March 8, 2021, to March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the safety glasses purchased December 15, 2020.
You asked the Plan to provide reimbursement for the safety glasses. You say that the Plan should provide reimbursement for the safety glasses. The Plan denied your request. The Plan says reimbursement cannot be provided because you did not use n plan provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a non provider. We looked at the file and the Plan's rules. You did not purchase the safety glasses from a non provider. Based on this information, we decided that the Plan's rules for coverage of the safety glasses have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for the safety glasses purchased December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) received November 16, 2020 from the out-of-network provider.
You asked the Plan to pay for the eye exam. You say that the claim should be processed and paid. The Plan denied your request. The Plan says criteria for obtaining out-of-network coverage were not met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased through a plan network optical provider. We looked at the file and the Plan's rules. The Plan contract states that in order to receive coverage, enrollees must receive their vision care through a plan network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) received November 16, 2020 from the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a participating provider on April 8, 2021.
You asked the Plan to waive the coinsurance for medical supplies. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for durable medical equipment (DME)/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed amount is $259.20. The total amount you are being asked to pay is $51.84 ($259.20 x 20% = $51.84). The correct coinsurance has been applied to the supplies that were provided. Medical supplies fall within the durable medical equipment (DME)/in-network 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 medical supplies provided by a participating provider on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invitae Lynch Syndrome Panel.
You asked the Plan to pre-approve Invitae Lynch Syndrome Panel. You say that without the requested treatment the enrollee could end up in the hospital. The Plan denied your request. The Plan says in order for the requested test to be covered the enrollee would need to have a personal history of a Lynch Syndrome hereditary-linked cancer.
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 Invitae Lynch Syndrome Panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of pancreatic cancer. The enrollee was diagnosed with poorly differentiated adenocarcinoma of the pancreas in 2019, and now has pulmonary metastases. It is documented that a detailed 3-generation pedigree was obtained from the enrollee, but it is not documented in the consultation note. A multigene panel was ordered. It has not been demonstrated that the requested testing is medically reasonable and necessary for the enrollee in this case, and that it is expected to impact the enrollee's management and outcome.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Invitae Lynch Syndrome Panel have not been met. Therefore, we decided that the Plan does not have to pre-approve Invitae Lynch Syndrome Panel.