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

We decided that the Plan does not have to pay for an office visit (99203, 90764, 90471) provided on November
18, 2020.
You asked the Plan to pay for the office visit. You say that the services should be covered. The Plan denied
your request. The Plan says the services were not emergent. There were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service
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 an office visit (99203, 90764, 90471) provided on November 18, 2020.
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. You do not appear to require inpatient mental health treatment as you are not a danger to herself or others and do not have any auditory or visual hallucinations while being cooperative with treatment. It does not appear that active treatment is taking place. It does not appear that the services are reasonably expected to improve your condition or for the purpose of diagnosis. 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy (90834) rendered by the out of network (OON) provider on January 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without 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 either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The provider in this case is not a network provider with the Plan. However, the Plan contract states that the enrollee can choose to receive care from out-of-network providers. The plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. Additionally, according to the contract there is no referral or prior authorization necessary when the enrollee receives care from out-of-network providers. Therefore, we decided that the Plan has to pay for the psychotherapy (90834) rendered by the out of network (OON) provider on January 21, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging, orbit, face, and/or neck (70540) provided on September 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the MRI. You say that you were told by the doctor that you would be covered for the service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being 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 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 magnetic resonance imaging, orbit, face, and/or neck (70540) provided on September 23, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy (90832) provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you are requesting review of the documents and processing of the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being 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 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 individual psychotherapy (90832) provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1/BRCA2 genetic testing services.
You asked the Plan to pre-approve the BRCA1/BRCA2 genetic testing services. You say that the enrollee needs to get the testing done as soon as possible. The Plan denied your request. The Plan says the requested testing is considered a screening and is excluded by Medicare statute.
The Plan follows Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 testing is covered for patients with a personal history of breast or ovarian cancer. 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 BRCA1/BRCA2 genetic testing services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a family history of malignant neoplasm of the breast, as well as cervical and uterine cancer. However, there is no evidence that the enrollee has a personal history of breast or ovarian cancer. 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 BRCA1/BRCA2 genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1/BRCA2 genetic testing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on March 9, 2021.
You asked the Plan to pay for the dental service. You say that this provider appears on the list of in network
providers. The Plan denied your request. The Plan says core build up is not listed as a covered service. The
Plan says that there is no record that you contacted the plan prior to the date of service to verify benefits. The
Plan also says that the dental benefits were emailed to you.
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, core build up is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up
(D2950) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on January 13, 2021.

You asked the Plan to pay for the services provided. You say that the claims have paid until the first of the year. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you may receive care from out-of-network providers. In some cases, you may need to get prior authorization from the plan. 

We looked at the file and the rules. 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 psychotherapy services provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retrograde filling (D3430) and apicoectomy (D3421)
provided on March 2, 2021.

You asked the Plan to pay for the retrograde filling and apicoectomy. You say that you believe these services
should be covered because they were more surgical related than they were for tooth repair. The Plan denied
your request. The Plan says these services are not covered.

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
retrograde filling (D3430) and apicoectomy (D3421) provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from Acute Inpatient Rehab that cannot be accomplished at a lower level of care.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for hiatal hernia repair and was treated for a femoral artery aneurysm. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (74018) provided February 25, 2021.
You asked the Plan to pay for the x-ray. You say that the x-ray was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 74018 is not supported in the medical record. Specifically, the claim was billed with Place of Service 22- outpatient, however, the record shows the enrollee was an inpatient at the time the services were rendered. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (74018) provided February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy represented by code 44207 provided on September 15, 2020.
You asked the Plan to pay for code 44207. You say that the medical records support the billing of CPT code 44207 provided on September 15, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 44207 provided on September 15, 2020.
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 44207 is Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis). 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 code 44207. Our reviewer says that the medical records do not support the billing of CPT code 44207 provided on September 15, 2020. Our physician reviewer found the operative note indicates that the enrollee underwent sigmoid resection and mobilization of splenic flexure via laparoscopic approach. The operative note states the anastomosis was performed between the descending colon and sigmoid colon. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 44207 have not been met. Therefore, we decided that the Plan does not have to pay for the Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy represented by code 44207 provided on September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vesiculectomy represented by code 55650 provided on December 4, 2020.

You asked the Plan to pay for code 55650. You say that the medical records support the billing of CPT code 55650 provided on December 4, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 55650 provided on December 4, 2020.

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 55650 is Vesiculectomy, any approach. 

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 code 55650. Our reviewer says that the medical records do not support the billing of CPT code 55650 provided on December 4, 2020. Our physician reviewer found the medical records do not support the billing of CPT code 55650 which is the code for seminal vesiculectomy when done as a separate procedure. Seminal vesiculectomy is considered a standard component of robotic prostatectomy (CPT 55866) and cannot be coded/billed separately.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 55650 have not been met. Therefore, we decided that the Plan does not have to pay for the Vesiculectomy represented by code 55650 provided on December 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you received from March 13, 2021, through March 15, 2021.
You asked the Plan to waive the copayment for the ER services. You say that your doctor advised you to go to the ER and you were admitted to receive antibiotic infusions. 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 $120 copayment for emergency room services. This amount is only waived if you are admitted as an inpatient within 24 hours for the same condition.
You have been asked to pay a $120 copayment for the ER services. The claims from these dates of service do not indicate that you were admitted as an inpatient to the hospital. Rather, you were kept in an observation status. That is why the emergency room copayment applies. 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 emergency room (ER) services you received from March 13, 2021, through March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services needed, in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for NSTEMI, coronary artery bypass grafting, respiratory failure and kidney failure. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-ray images (D0210) provided on February 26, 2021.
You asked the Plan to pay for the x-rays. You say that this service was necessary. The Plan denied your request. The Plan says this type of x-ray is not covered by your dental benefit.
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 complete series of intraoral x-ray images (D0210) provided on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care. 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 acute inpatient rehabilitation facility (IRF) admission and services.