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

We decided that the Plan does not have to pay for emergency room services (99285, 93010) provided
November 10, 2020.
You asked the Plan to pay for emergency room services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim did not include a valid diagnosis 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.
We find that CPT code 99285 & 93010 is not supported in the medical record. Specifically, the diagnosis code
listed is not a valid primary code. The underlying condition must be listed first. Based on this information, we
decided that Medicare rules for coverage of emergency room services have not been met. Therefore, we
decided that the Plan does not have to pay for emergency room services (99285, 93010) provided November
10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 1, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says genetic testing was not ordered/approved by treating provider.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds (76700, 76857) provided September 4, 2020.
You asked the Plan to waive the copayments for the ultrasounds. You say that the copayments should be waived The Plan denied your request. The Plan says the correct copayments were 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 $125 copayment for diagnostic radiology. You have been asked to pay a copayment of $108.51 and $43.04 for the ultrasounds. The ultrasounds fall within the diagnostic radiology benefit category. The allowable amounts of $108.51 and $43.04 are less than the $125 per-service copayment specified 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 copayments for ultrasounds (76700, 76857) provided September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97530) provided November 5, 2020 to November 13, 2020.
You asked the Plan to pay for the physical therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim included an incorrectly used modifier and this CPT code is not separately 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 97530 is not supported in the medical record. Specifically, the services provided are included in CPT code 97140 which was also billed on the same day. The use of modifier 59 to denote a distinct service is not supported in the documentation. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97530) provided November 5, 2020 to November 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 28, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says this enrollee 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 a 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 reasonable and necessary. 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) provided September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020), spherocylinder lens (V2204), photochromic
tint (V2744), anti-reflective coating (V2750), and polycarbonate or equal lens (V2784) received on December
16, 2020.
You asked the Plan to pay for frames, spherocylinder lens, photochromic tint, anti-reflective coating, and
polycarbonate or equal lens. You say that you do not understand why the Plan will not cover these items. The
Plan denied your request. The Plan says the benefit limit of one pair of lenses and frames every two years has
been exceeded.
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.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of frames, spherocylinder lens, photochromic tint, anti-reflective coating, and polycarbonate or equal
lens have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this
service on July 10, 2020. Additionally, tint, anti-reflective coating, and polycarbonate are not covered services.
Therefore, we decided that the Plan does not have to pay for frames (V2020), spherocylinder lens (V2204),
photochromic tint (V2744), anti-reflective coating (V2750), and polycarbonate or equal lens (V2784) received
on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 12, 2020.
You asked the Plan to pay for a limited oral evaluation. You say that you do not understand why the Plan would not cover this service and you would like the Plan to reconsider. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one per plan year.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on August 24, 2020. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D9430, D0272, D0220).
You asked the Plan to pay for the dental services (D9430, D0272, D0220). You say that you did not request these services, therefore you should not have to pay for them. The Plan denied your request. The Plan says the requested services are either excluded from coverage or exceed the plan's annual benefit allowance.
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. The Plan does not cover D9430 (office visit for observation). The Plan limits coverage of preventative x-rays to two per calendar year. The Plan has submitted evidence that you exhausted this benefit on January 5, 2020, therefore, the Plan does not have to cover D0272 (bitewing x-ray) and D0220 (periapical first radiographic image). Therefore, we decided that the Plan does not have to pay for the dental services (D9430, D0272, D0220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910).
You asked the Plan to pay for the periodontal maintenance. You say that a more intense cleaning was required
because your provider cancelled your previous appointment due to the pandemic. The Plan denied your request.
The Plan says the requested service is excluded under your supplemental 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. Periodontal maintenance is specifically listed as a benefit exclusion on
page 7 of the Summary of Dental Plan Benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance (D4910).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81551) provided November 19, 2020.
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan
denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85
years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being
considered for a repeat biopsy.
We looked at the file and Medicare rules. The record shows the enrollee has not received a previous cancer
negative prostate biopsy. Based on this information, we decided that Medicare rules for coverage of the genetic
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81551)
provided November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 1, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided on September 22, 2020.
You asked the Plan to pay for continuous glucose monitor supplies (K0554, K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no physician order or proof of delivery documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. There is no physician order, delivery ticket or proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided on September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on November 30, 2020, to December 10, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not feel like you received adequate care. The Plan denied your request. The Plan says the correct copayment 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 $305 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $305 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,525 ($305 x 5 days = $1,525). Since inpatient hospital services were provided, the correct copayment has been applied. An 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 an inpatient hospital stay provided by a participating provider on November 30, 2020, to December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient care provided from October 12, 2020, to October 13, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that inpatient care was 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 documentation submitted by the Plan does not contain medical records from the in-network provider for the dates of service in question. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the inpatient care provided from October 12, 2020, to October 13, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (98940, 99202) provided November 2,
2020.
You asked the Plan to pay for the chiropractic services. You say that the services should be covered. The Plan
denied your request. The Plan says coverage rules were not met.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. CPT code 98940 was billed
without a missing modifier. Therefore, we decided that the Plan does not have to pay for chiropractic services
(98940, 99202) provided November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on December 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee admitted for weakness and a fall and was discharged to skilled nursing facility. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.