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

We decided that the Plan does not have to pay for the physician services rendered on May 14, 2020.
You asked the Plan to pay for these services. You say that the claim denied in error. The Plan denied your
request. The Plan says the claim has not been processed by the primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed
that you were covered by a different primary insurer for the date of service at issue. The claim has not been
processed by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for these
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan
does not have to pay for the physician services rendered on May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for syncope. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need foran intensive rehabilitation program. 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.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-approveacute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea power wheelchair or scooter.You asked the Plan to preapprovethe power mobility device. You say that you'd like the claim to be approved.The Plan denied your request. The Plan says you have not had a required face to face encounter documented.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. You have not had an appropriate The file shows that you have not had a face to face encounter to determine if you meet the criteria described. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to preapprovea power wheelchair or scooter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on October 27, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you have never had to pay a separate 
copayment for an x-ray. You say you should not owe it now. 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 $20 
copayment for each in-network Medicare-covered standard x-ray and ultrasound.  
 
You have been asked to pay a $20 copayment for the x-ray. The x-ray falls within the ?Outpatient diagnostic 
tests and therapeutic services and supplies? 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 x-ray provided on October 27, 2020.  
 
Our decision is only about the October 27, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for screening mammography and screening digital breast tomosynthesis provided on June 12, 2020.
You asked the Plan to pay for screening mammography and screening digital breast tomosynthesis. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the original claim was paid on July 2, 2020 and this is a duplicate claim.
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 additional units of CPT code 77063, 77067 are not supported in the medical record. Specifically, the original claim was paid and there is no additional documentation supporting additional studies. Based on this information, we decided that Medicare rules for coverage of screening mammography and screening digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for additional screening mammography and screening digital breast tomosynthesis provided on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-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 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 lab services provided on September 15, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 7, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require 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 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
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 nurse practitioner services provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on June 25, 2020.
You asked the Plan to pay for the dental services. You say that this code was covered in 2018 and 2019. You
say that you would like to know if there is a different code that should have been used. You say that you had to
have this service done because you have periodontal disease. You also say that The Plan denied your request.
The Plan says the comprehensive periodontal evaluation is not listed as a covered service.
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
comprehensive periodontal evaluation (D0180) provided on June 25, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the hip x-ray (73501) provided on August 17, 2020. 
 
You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration because this service 
was denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 73501 is a 
column II code to CPT code 73502. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to 
NCCI edits. 
 
We find that CPT code 73501 is supported in the record. Specifically, the record indicates that CPT codes 
73501 and 73502 were rendered by different providers with different NPIs. It is not appropriate to apply NCCI 
edits to services rendered by different providers with separate NPIs. Based on this information, we decided that 
Medicare rules for coverage of the hip x-ray have been met. Therefore, we decided that the Plan has to pay for 
the hip x-ray (73501) provided on August 17, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital services beyond January 23,
2021.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital on January 9, 2021 with metabolic encephalopathy. On January 23, 2021 it was documented that there
were no new issues and the enrollee was not in acute distress. The physical exam was notable for drowsiness
and confusion. Laboratory studies were not actionable. The records do not support that the continued inpatient
level of care is reasonable or medically necessary at this time.
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 pre-approve continued inpatient hospital services beyond January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth (D7220) for 3 additional teeth provided on August 19, 2020.
You asked the Plan to pay for the removal of an impacted tooth for 3 additional teeth. You say that you were not told that you were only allowed 2 to 3 teeth pulled per year. The Plan denied your request. The Plan says 2 oral surgery procedures per calendar year are covered. The Plan says that the benefit for this service has been exhausted. The Plan says that you did not contact the plan to verify your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit of 2 oral surgery procedures per calendar year has been exhausted. The record shows that the Plan paid for the 2 of the oral surgery procedures that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the removal of an impacted tooth (D7220) for 3 additional teeth provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system and supplies. 
 
You asked the Plan to pre-approve the Volara system and supplies. You say that the requested services are 
medically reasonable and necessary. The Plan denied your request. The Plan says a review of the current 
medical literature indicates that this service is considered experimental and investigational as it is not identified 
as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed 
medical literature published in the English language. 
 
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 Volara system and supplies. Our 
reviewer says that the Volara system and supplies are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested device delivers chest wall oscillation as well as positive 
airway pressure.  This treatment has not been clearly shown to be beneficial in the treatment of asthma.  The 
enrollee does not have a diagnosis of cystic fibrosis, bronchiectasis, or generalized neuromuscular disease.  
 
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 Volara system and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Volara system and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 16, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0435) provided on September 4, 2020 from place of residence to a medical office and back.
You asked the Plan to pay for non-emergent ambulance and ground mileage. You say that the service was medically necessary. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Ambulance transportation to a medical office is not a covered service. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0435) provided on September 4, 2020 from place of residence to a medical office and back.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750) and a pontic (D6240). 
 
You asked the Plan to pre-approve the retainer crown and pontic. You say that the imaging provided supports 
the need for the requested services. The Plan denied your request. The Plan says the services in dispute 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 pre-approve a 
retainer crown (D6750) and a pontic (D6240).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating
provider on September 4, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you do not think it is fair to be charged
for these x-rays. 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 $40
copayment for outpatient diagnostic tests/basic imaging services.
You have been asked to pay a $40 copayment for an x-ray. Since x-rays were provided, the correct copayment
has been applied. An x-ray falls within the outpatient diagnostic tests/basic imaging services 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 x-ray provided by a participating provider on September
4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) provided March 30, 2019 to April 
20, 2019. 
 
You asked the Plan to pay for infrared therapy. You say that enclosed are medical records in detail pertaining 
to the enrollee for service rendered. The Plan denied your request. The Plan says infrared therapy is considered 
not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
infrared therapy (97026) provided March 30, 2019 to April 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 8, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for these services. You say that you did not want to have a biopsy done. The Plan
denied your request. The Plan says the services were 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 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 laboratory services provided on July 8, 2020
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care from January 20, 2021, through January 27, 2021.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cerebrovascular accident. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. 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 IRF care from January 20, 2021, through January 27, 2021.