Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 27, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that you would like periodontal cleanings to be covered by the Plan. The Plan denied your request. The Plan says this service is not covered under your dental plan 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. 

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 periodontal maintenance (D4910) provided on April 27, 2021.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 indicating medical necessity for admission to a LTACH. You are receiving appropriate care at the present acute care hospital and do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being obtained at your current level of care and you do not require any additional services. This means admission into an LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the family planning (99403) provided on February 4, 2021.

You asked the Plan to pay for the family planning. You say that the service code billed is a payable code per the Medicaid fee schedule. The Plan denied your request. The Plan says the service in this case is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 

We looked at your request, the file and Medicare rules. Based on this information we decided that Medicare rules for coverage have not been met. Specifically, per Medicare, procedure code 99403 has a status code of N. This means that this service is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the family planning (99403) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 17, 2021.
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 36247 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 36247 is selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. We find that CPT code 36247 is not supported in the medical record. Specifically, there is no documentation of selective third order catheterization of the abdominal, pelvic, or lower extremity artery. 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 surgical services rendered on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination (88304) provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that the services you billed for was referred to you by an authorized provider, you request the claim to be reviewed and reconsidered for payment of the laboratory services. 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 the surgical pathology, gross and microscopic examination (88304) provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and implant supported crown provided on May 5, 2021.
You asked the Plan to pay for the custom fabricated abutment and implant supported crown. You say that you believe you are covered for a benefit amount of $1,000. The Plan denied your request. The Plan says the services are not covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and implant supported crown provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection.

You asked the Plan to pre-approve the cervical epidural steroid injection. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says there is no documentation of conservative management having been tried or failed.

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 the cervical epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of documentation indicating the inability to tolerate a trial of conservative treatments such as, non-steroidal analgesics, heat, ice, physical therapy, and other considerations, such as acupuncture. 

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 cervical epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physician services and laryngoscopy.
You asked the Plan to waive the deductible for physician services and laryngoscopy on April 9, 2021. You say that you had an office visit with the provider. You say there is a claim for a procedure that was not performed, and you should not have to pay the deductible. 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. Your contract with the Plan says that there is a $1300 deductible for all items and services except those specifically excluded by the Plan contract. You have been asked to pay $169.08 for physician services and $127.45 for a laryngoscopy, for a total of $296.53. The medical records show you received both services. Physician services fall within the benefit category Physician/Practitioner services, including doctor's office visits. Laryngoscopy falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1300 deductible, which applies to Physician/Practitioner services, including doctor's office visits and Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time physician services and laryngoscopy was received on April 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for physician services and laryngoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network provider.
You asked the Plan to pre-approve a second opinion with an out-of-network provider. You say that you want a second opinion with an out-of-network provider. The Plan denied your request. The Plan says the care required to treat your diagnosis is available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 the enrollee is an 84-year-old female who was admitted to the current acute care hospital with PE and acute respiratory failure requiring an inferior vena cava (IVC) filter placement, ex lap with removal of old mesh and repair with component separation sub rectus and transversus abdominal release and strattice graft. The enrollee required a blood transfusion, a right hemicolectomy for dilated colon, wound vac, wound debridement, antibiotics, JP drain, and mechanical ventilation. Recent notes state the enrollee is not currently weaning yet and is not a candidate for percutaneous endoscopic gastrostomy (PEG) due to wound. The enrollee appears to be currently unstable, requiring short-term additional acute care services to wean and stabilize feeding and respiratory status which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.
Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time would not provide a clinical advantage. Transfer may be considered when the enrollee is more stable and when treatment has completed. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pre-operative physical therapy evaluation you had at an orthopedist's office on January 15, 2021.
You asked the Plan to waive the copayment for the pre-operative physical therapy evaluation at an orthopedist's office. You say that you had a few appointments on this date in preparation for knee surgery you had on January 26, 2021. You stated that PT did not start until after your surgery, so you should not have to pay a copayment. 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 $35 copayment for visits to a specialist's office. You have been asked to pay a $35 copayment for the pre-operative physical therapy evaluation at an orthopedist's office. The pre-operative physical therapy evaluation at an orthopedist's office falls within the visits to a specialist's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the pre-operative physical therapy evaluation you had at an orthopedist's office on January 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on March 23, 2021.
You asked the Plan to pay for the chest x-ray. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on March 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 9, 2019.
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 codes 95955, 95910, 95885, and 95937 are 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 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95910 is nerve conduction studies; 7-8 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List
separately in addition to code for primary procedure). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.
We find that CPT codes 95955, 95910, 95885, and 95937 are not supported in the medical record. Specifically, there is no documentation of EEG during nonintracranial surgery to support code 95955. There is no documentation of 7-8 nerve conduction studies to support code 95910. There is no documentation of needle electromyography to support code 95885. There is no documentation of neuromuscular junction testing to support code 95937.
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 testing services rendered on July 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation services (T2005, T2049) provided on November 8, 2020.
You asked the Plan to pay for transportation services. You say that this service was provided in good faith. The Plan denied your request. The Plan says this was not billed with valid codes.
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 codes T2005 and T2049 are not supported in the medical record. Specifically, these codes
have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of transportation services have not been met. Therefore, we decided that the Plan does not have to pay for transportation services (T2005, T2049) provided on November 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the introduction of a needle or an intracatheter (36140-XS) provided on December 29, 2020.

You asked the Plan to pay for the introduction of a needle or an intracatheter. You say that this is supported in the records. The Plan denied your request. The Plan says this 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. In this case, we have confirmed that code 36140 has a bundled relationship with code 37226 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 the introduction of a needle or an intracatheter (36140-XS) provided on December 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on December 9, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 modifier. 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 digital breast tomosynthesis rendered on December 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from February 10, 2020, to February 13, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with J96.01. 

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 services. Our reviewer says that the use of diagnosis code J96.01 is not supported in this case. Our physician reviewer found that the enrollee was treated with supplemental oxygen of 2L/min via nasal cannula. ED provider assessment states "Respiratory- no acute distress, respiratory effort: spontaneous, nonlabored, regular." Critical care progress notes and general medicine progress notes assess the enrollee's respiratory status as "CTAB", "nonlabored", "in not acute distress. The review has determined that the use of secondary diagnosis code J96.01 is not supported by the records provided. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from February 10, 2020, to February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on October 13, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for dermatology services. You say that you were unaware that you were out-of-network. You say that is why prior authorization was not obtained. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 dermatology services provided on October 13, 2020 by an out-of-network (OON) provider.