Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray equipment transportation services (HCPCS
R0070) provided to the enrollee on January 6, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this code has a TC indicator of 3, per the 2020 National Physician Fee Schedule Relative Value
File January Release.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of HCPCS code R0070 is "Transportation of portable x-ray
equipment and personnel to home or nursing home, per trip to facility or location, one patient seen."
We asked our coding 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
services at issue in this case were not coded correctly. Our coding reviewer found Indicator 3 Technical
components only codes: this indicator identifies stand-alone codes that describe the technical component (i.e.,
staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the
professional component of the diagnostic tests only.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for portable x-ray equipment transportation services (HCPCS R0070) provided to the enrollee on
January 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on
August 7, 2019.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you disagree with
the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct 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 $0
copayment for mammography and ultrasounds and a $270 copayment for all other diagnostic and nuclear
medicine radiological services.
You have been asked to pay a $270 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging 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 myocardial perfusion imaging provided on August 7, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided October 1, 2018
to November 16, 2018.
You asked the Plan to pay for the outpatient mental health services. You say that the claim should be paid. The
Plan denied your request. The Plan says the claim was not submitted timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the outpatient mental health services was not filed until January 3, 2020. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided
October 1, 2018 to November 16, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records signed by the
ordering physician stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins
when required (D2950) for tooth #6 provided on September 9, 2019.
You asked the Plan to pay for the crown and core buildup. You say that the enrollee has had endodontic
therapy on tooth # 6. You also say the enrollee's tooth has lingual decay and fractures. The Plan denied your
request. The Plan says the crown and core build up are not medically necessary.
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 the crown and
core buildup 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 pay for the crown and core buildup. Our reviewer
says that these services are not medically necessary. Our physician reviewer found the endodontic fill is clearly
more than 3 mm short of the apex, and the clinical apex of the root cannot be seen on the supplied x-ray. The
supplied x-ray is a post treatment film, and the pre-treatment condition of the tooth is not able to be determined.
The pre-treatment condition of the tooth is unknown aside from the description provided of there being lingual
decay and fractures present. Our reviewer found that there does appear to be a significant amount of filling or
core material present around the area of the crown on the x-ray. A pre-treatment x-ray would be required to
assess the need for the procedures that were completed, and this has not been provided.
Our reviewer also found that given the short endodontic fill making for a questionable long term prognosis, and
the lack of a pre-treatment x-ray to allow for assessment of the tooth prior to treatment, there is no medical
necessity for the requested procedures.
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 the crown and core buildup have not been met. Therefore, we decided that the
Plan does not have to pay for the crown (D2740) and core buildup, including any pins when required (D2950)
for tooth #6 provided on September 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of
an inpatient rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs do not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical
status does not require intensive physician or nursing oversight in an inpatient rehabilitation facility. You may
benefit from additional multiple therapies; however, your functional level does not require or indicate that this
therapy must be provided in an inpatient rehabilitation facility with an intensive level program.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 reviewer found based on the medical records provided, you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that are not available at the health care setting being offered by the health plan. Medicare coverage criteria for transfer to an LTACH are not met. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's current medical conditions and treatment along with her past medical history support the reason she would benefit from an acute intensive rehab program. The Plan denied your request. The Plan says the submitted documentation does not support the medical necessity of care in an acute IRF.
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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's high functional level does not require or indicate that this therapy must be in an IRF with an intensive level program 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (CPT 88112) provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied because it was reported twice for the same date of service, once with modifier 26 (professional component), and once without a modifier (global service).
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 88112 is "Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal." We asked our coding 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 services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted was reviewed, and it is not appropriate to bill this code twice on the same day. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for cytopathology services (CPT 88112) provided to the enrollee on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for programing device evaluation provided on
January 20, 2020.
You asked the Plan to waive the copayment for programing device evaluation. You say that this was a followup
visit and you were told that you would not owe a copayment. The Plan denied your request. The Plan says
the claims were processed correctly and you are being charged the correct 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 $30
copayment for specialist services.
You received programming device evaluation on January 20, 2020. Follow-up visits are subject to cost-sharing
charges. Therefore, you are responsible to pay the $30 copayment.
You have been asked to pay a $30 copayment for programing device evaluation. Programing device evaluation
falls within the physician/practitioner services, including doctor's office visits 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 programing device evaluation provided on January 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (G0279, 77066)
provided February 10, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $200
copayment for Outpatient Hospital Services including radiology.
You have been asked to pay a $200 copayment for the diagnostic mammogram. The diagnostic mammogram
falls within the Outpatient Hospital Services. 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 a diagnostic
mammogram (G0279, 77066) provided February 10, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for FoundationOne CDx testing provided on June 11, 2019.
You asked the Plan to pay for genetic test. You say that this test is covered by Medicare and was medically
reasonable and necessary for management of the enrollee's condition. The Plan denied your request. The Plan
says that the denial of payment for this service is correct.
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-
network with the Plan. The documentation submitted did not include prior notice from the Plan that this
testing would not be covered. Without this information, we cannot determine whether the lab order made
constitutes plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this
service is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for
FoundationOne CDx testing provided on June 11, 2019.
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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 8, 2020 to January 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that that medical need for inpatient was not shown.
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. The enrollee was brought by family for the evaluation of increased confusion. 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. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 8, 2020 to January 10, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power wheelchair components/accessories.
You asked the Plan to pay for the accessories. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested accessories are incorrectly coded and not reasonable and necessary.
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 the denied codes is:
K0108 Wheelchair component or accessory, not otherwise specified - SmartDrive Power Assist x1
K0108 Wheelchair component or accessory, not otherwise specified - Newton Ultra Caster composites (ultra
castor wheels) x1
K0108 Wheelchair component or accessory, not otherwise specified - Aluminum Back Canes x1
K0108 Wheelchair component or accessory, not otherwise specified - wheel extensions x1
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 accessories. Our reviewer says that the
requested accessories were not coded correctly in this case. Our physician reviewer found K0108 = SmartDrive
Power Assist is to be used for an existing chair, not a new chair. K0108 = Newton Ultra Caster composites
cannot be unbundled. K0108 = Aluminum back canes cannot be unbundled. They are part of K0005. K0108 =
Wheel extensions should be coded E0961.
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 accessories have not been met. Therefore, we decided that the Plan does not
have to pay for power wheelchair components/accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on December 20, 2019.