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

We decided that the Plan does not have to pay for laboratory services provided on December 20, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 provided on December 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 78014 provided on December 24, 2019.
You asked the Plan to pay for CPT code 78014. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. In this case, CPT code 78014 is a column two code and cannot be billed with column one code, 79005. Therefore, we decided that the Plan does not have to pay for CPT code 78014 provided on December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous passive motion exercise device provided from January 1, 2020 to January 24, 2020.
You asked the Plan to pay for the continuous passive motion exercise device. You say that this device was prescribed for you after surgery. The Plan denied your request. The Plan says that this device is not covered but you are not responsible for the cost.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the continuous passive motion exercise device by a contract provider. The file does not show that the Plan provided notice that the continuous passive motion exercise device would not be covered. Under Medicare rules, this means the continuous passive motion exercise device is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the continuous passive motion exercise device provided from January 1, 2020 to January 24, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a dental crown. You asked the Plan to pre-approve the crown. You say that the crown is necessary. The Plan denied your request. The Plan says that the crown is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan indicates that the requested crown is not medically necessary. However, the plan has not provided x-rays for review. Several attempts were made to obtain the required x-rays from the plan. Without dental x-rays, a determination of medical necessity cannot be made, and the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pre-approve a dental crown.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not have a need for intensive rehab, or a multidisciplinary team for 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 above. 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 physician reviewer found that the enrollee is generally medically stable after a total knee replacement on the left. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently the enrollee is at maximum assist due to pain, but was walking with a walker the day before. While the enrollee may benefit from continuing physical therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. There are no physical or occupational therapy evaluations to prove any of the documented function in the pre-admission screening. Therefore, the requested services are 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided July 10, 2019.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says payment for this service has been bundled with payment for another code.
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, we have confirmed that code 71045 has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not have complex medical conditions which require physician supervision, or a need for a multidisciplinary team for 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 above. 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 physician reviewer found that you are medically stable after thoracic spine decpmpressive surgery for spinal stenosis with acute medical complications. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently you are at a moderate assist level. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection provided on December 5, 2019.
You asked the Plan to waive the copayment for the sacroiliac joint injection. You say that you went to a pain clinic not a surgical center. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each visit for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center. You have been asked to pay a $250 copayment for the sacroiliac joint injection. The sacroiliac joint injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the injection was billed by the hospital. 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 sacroiliac joint injection provided on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on January 21, 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 were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific criteria are met. 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 these services.
Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee is on hydrocodone and pregabalin for pain management. The records do not support that the definitive drug testing meets the Medicare criteria for coverage or that the testing was reasonable and medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing rendered on January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the wrist (73100) provided January 28, 2020.
You asked the Plan to waive the copayment for the x-ray of the wrist. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $35 copayment for x-rays. You have been asked to pay a $30.83 copayment for the x-ray of the wrist. The Medicare allowable amount of $30.83 is less than the amount ($35) stipulated in the plan contract. 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 x-ray of the wrist (73100) provided January 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the cervical and thoracic spine (72156, 72157) provided November 7, 2019.
You asked the Plan to pay for the MRI's. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do 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. In this case, the CPT Code Manual definition of codes 72156 & 72157 are MRI with and without contrast of the cervical spine, and MRI with and without contrast of the thoracic spine. We find that CPT codes 72156 & 72157 are not supported in the medical record. Specifically, the limited records provided only pertain to an MRI of the Lumbar Spine which has already been approved by the health plan. There are no clinical records for the procedures at issue despite multiple attempts by the health plan to obtain them. Based on this information, we decided that Medicare rules for coverage of the MRI's have not been met. Therefore, we decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the cervical and thoracic spine (72156, 72157) provided November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a pontic on tooth #8 and crowns for teeth #7 and #9 for the enrollee.
You asked the Plan to pre-approve these services. You say that these services should be covered. The Plan denied your request. The Plan says that that documents fail to demonstrate a specific medical condition (physical or physiologic) that would preclude the use of a removable partial denture.
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 these services 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 these services. Our reviewer says that these services are medically reasonable and necessary for the enrollee in this case. Crowns are required to restore teeth #'s 7 and 9 to normal function. Because the crowns are required the use of a fixed bridge to replacing missing tooth #8 is reasonable and necessary. A removable partial would not be the treatment of choice for the replacement of missing tooth #8. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these services. 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a pontic on tooth #8 and crowns for teeth #7 and #9 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Emergency Room visit (99285) provided November 15, 2019.
You asked the Plan to waive the copayment for the Emergency Room Visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for Emergency Care. The enrollee has been asked to pay an $80 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care benefit category. In this case, the applied copayment of $80 is less than the plan contract stipulated amount of $90 because the enrollee had met the maximum out-of-pocket cost at the time the services were provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the Emergency Room visit (99285) provided November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 24, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you had the procedure done at the provider's office and you should not be charged. 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 a $300 copayment for surgery services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 copayment for the arthrocentesis.
You have been asked to pay a $243.22 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you received the service at an outpatient hospital facility.
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 arthrocentesis provided on January 24, 2020.
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 you are appealing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. While you may benefit from additional multiple therapies such as physical therapy and occupational therapy, you do not require an intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from December 25, 2019 to December 31, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that that these services were medically necessary. The Plan denied your request. The Plan says that that the patient could have been managed at an observation level of care.
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 that the enrollee presented to the emergency department with shortness of breath for one day and confusion. The enrollee's condition stabilized and improved with medical treatment and she was discharged back to the nursing facility when she was considered medically stable. 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 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 to the enrollee from December 25, 2019 to December 31, 2019.