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

We decided that the Plan does not have to pay for the medical services rendered on May 23, 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 99053 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99053 (services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on May 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 25, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that you disagree with this copayment. You say then enrollee was sent to this hospital. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment per emergency department visit depending on the plan in which you are enrolled.

The enrollee has been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 19, 2021.
You asked the Plan to pay for the dental service. You say that you went to the dentist on August 17, 2021, for a toothache. You say that you were advised you needed a root canal and were referred to another dentist. You say that that dentist did another evaluation to verify the problem. You also say that this was an emergency situation and should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.
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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on August 17, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia for procedures on eye provided on June 15, 2021.
You asked the Plan to pay for the anesthesia for procedures on eye. You say that you shouldn't have to pay anything for the services in dispute. The Plan denied your request. The Plan says that out of network vision care services and materials are not covered. The Plan says that the enrollee has no out of network plan benefits to reimburse him for the services rendered.
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. Specifically, the Plan has not substantiated their denial reason. There is no evidence that the anesthesia for procedures on eye was performed in a routine setting and not for diagnostic treatment. There were no medical records provided to demonstrate the type of eyecare that was provided. There is no evidence that the Plan made reasonable attempts to obtain this necessary information from the provider. The Plan contract states that the enrollee does have out of network coverage for covered vision services. Therefore, we decided that the Plan has to pay for anesthesia for procedures on eye provided on June 15, 2021.
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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on July 19, 2021, billed with code 95941.

You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your request. The Plan says this was billed using a code that is not payable by Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Code 95941 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on July 19, 2021, billed with code 95941.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 in this case, the complexity of your nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography of the abdomen with contrast material (74160) provided on February 5, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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. Additionally, you must pay a $225 copayment for all other diagnostic and nuclear medicine radiological services.

You have been asked to pay $190.33 for the diagnostic radiological service provided. This is the Plan's allowed amount for this service which is less than the applicable copayment. 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 computed tomography of the abdomen with contrast material (74160) provided on
February 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridements (11043 and 11046), negative pressure wound therapy (97605), and subsequent nursing facility care (99307) provided on June 7, 2021.

You asked the Plan to pay for the debridements, negative pressure wound therapy, and subsequent nursing facility care. You say that the wounds were not related to the terminal condition for which the enrollee was placed on hospice. 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 debridements (11043 and 11046), negative pressure wound therapy (97605), and subsequent nursing facility care (99307) provided on June 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on August 31, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $120 copayment for emergency care for Inland Empire or Los Angeles and Orange counties plan members.
You have been asked to pay a $120 copayment for the emergency care provided. 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 emergency room visit (99285) provided on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug panel testing provided on January 7, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says one code must be submitted for the panel.
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 looked at the file and the rules. If one laboratory procedure evaluates multiple genes, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the drug panel testing provided on January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan of the thorax.
You asked the Plan to pay for LDCT scan. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no medical records were provided to establish medical necessity criteria had been met.
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. In this case, no medical records were provided despite the Plan's efforts. Without these medical records, we cannot determine the medical necessity of the provided imaging services. Based on this information, we decided that Medicare rules for coverage of LDCT scan have not been met. Therefore, we decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan of the thorax.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on
April 13, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 laboratory services provided at an outpatient hospital or urgent care center. You have been asked to pay a $35 copayment for the laboratory services provided at an outpatient hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided on April 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits.
You asked the Plan to pre-approve 6 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 6 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. As such, the requested home health skilled nursing services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 1, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 70450 was billed with code 70496. CPT code 70450 may be eligible for payment when billed with this code pair. The claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on July 14, 2021.
You asked the Plan to pay for the testing services. You say that the services were medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular genetic risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The records provided do not show that the results of testing will impact clinical management of this specific enrollee's condition. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for reconstructed breast revision (19380) provided on July 13, 2021.
You asked the Plan to pay for reconstructed breast revision. You say that this was billed correctly. The Plan denied your request. The Plan says this cannot be paid as billed during the postoperative period.
The Plan must follow Medicare rules. Medicare rules say that when treatment for complications requires a return trip to the operating room, physicians must bill modifier "-78" for these return trips (return to the operating room for a related procedure during a postoperative period) along with the code that describes the procedure(s) performed during the return trip. We looked at the file and Medicare rules. The service at issue was treatment for a complication during the postoperative period of the tissue expander replacement performed on April 22, 2021, by the same provider, but the service at issue was not billed with modifier -78. Based on this information, we decided that Medicare
rules for coverage of reconstructed breast revision have not been met. Therefore, we decided that the Plan does
not have to pay for reconstructed breast revision (19380) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on April 21, 2021.
You asked the Plan to pay for the dental service. You say that the crowns were necessary because the old ones
were broken with open margins. You say that you were experiencing pain and discomfort. You also say that the
services were previously approved. The Plan denied your request. The Plan says 3 crowns are covered per year.
The Plan also says that the frequency limit has been exceeded.
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 and crowns are listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for 1 crown that you received on
March 31, 2021, and 2 crowns that you received on April 21, 2021. Additionally, the file shows that the
predetermination of benefits states that it is not a guarantee of payment. Therefore, we decided that the Plan
does not have to pay for the porcelain crown (D2740) provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that the provider had no information about you or this service and you want it off your record. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 laboratory testing provided on August 11, 2021 by an out-of-network (OON) provider.