Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 28, 2020 to
July 31, 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 submitted records do not support the billing of diagnosis code E87.1.
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 diagnosis code E87.1 (hypo-osmolality and
hyponatremia). 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 these services. Our
reviewer says that the submitted records do not support the billing of diagnosis code E87.1. Our physician
reviewer found the enrollee presented to the hospital with speech difficulty, slurred speech, and bilateral lower
extremity weakness. She was admitted to manage an acute right pons stroke. Magnetic resonance imaging
(MRI) of the brain showed a recent infarction involving the right pons. The records do not support the billing
of diagnosis code E87.1.
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 hospital services rendered from July 28, 2020 to July 31, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit (99285) provided on December 22,
2020.
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285.
The Plan denied your request. The Plan says the medical records do not support the billing of code 99285.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect
the services provided.
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the
evaluation and management of a patient which requires three components (taking into account the urgency of
the clinical condition or the patient's mental status):
1. a comprehensive history;
2. a comprehensive examination; and
3. medical decision making of high complexity.
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate
significant threat to life or physiologic function.
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 code 99285 Our reviewer says that the
medical records do not support the billing of code 99285. Our reviewer found while nursing, laboratory,
radiographic and discharge documentation has been submitted for review, no provider records have been
submitted for review. Therefore, the billing of CPT 99285 is not supported. There is no documentation of a
history, examination or assessment having been completed by a provider, or documentation of the level of such
a history, examination or assessment (i.e. detailed, expanded, comprehensive).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not
have to pay for the emergency room visit (99285) provided on December 22,2020.
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 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 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. The enrollee can be treated safely in another setting. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 skilled nursing (SN) visits in the home health setting.
You asked the Plan to pre-approve the 12 requested SN visits. You say that you are not able to reach your
wound to change bandages and clean it which needs to be done by a skilled nurse. The Plan denied your
request. The Plan says you do not meet the criteria for skilled home health care.
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 the 12 requested SN visits. Our reviewer says that the documentation does not support that skilled nursing care in the home health setting is medically reasonable and necessary. Our physician reviewer found the enrollee is a female with surgical procedures done in June and July 2021, requiring wound care. The enrollee has been seen in a wound clinic, but requests help with bandage changes and wound cleaning. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). As such, the requested, ongoing home health SN 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 the 12 requested SN visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 skilled nursing (SN) visits in the home health setting.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (70450) provided on July 28, 2021.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the records do not support the payment of duplicate claims.
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 70450 is Computed tomography, head or brain; without contrast material. We find that CPT code 70450 is supported in the medical record. Medicare says for claims to be considered exact duplicates, certain elements must match. In this case, the provider billing numbers do not match, and the billed amounts do not match. Based on this information, we decided that Medicare rules for coverage of code 70450 have been met. Therefore, we decided that the Plan has to pay for the computed tomography (70450) provided on July 28, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on October 21, 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 code 97530 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, there is no documentation of
15 minutes of therapeutic activities with direct patient contact. 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 physical therapy services rendered on October 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay wheelchair van services provided on April 14, 2021.
You asked the Plan to pay for wheelchair van services. You say that there was no other way of being
transported. The Plan denied your request. The Plan says a wheelchair van (chair car) transportation is not
covered by Medicare even if provided by an ambulance company.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.
The services you have asked the Plan to pay are wheelchair van transport services. Therefore, we decided that
the Plan does not have to pay wheelchair van services provided on April 14, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tobacco counseling for the control and prevention of oral disease (D1320), and full mouth debridement (D4355) provided on April 30, 2021.
You asked the Plan to pay for the tobacco counseling and full mouth debridement. You say that you do not understand why the services are not covered. The Plan denied your request. The Plan says tobacco counseling is not listed and therefore is not a covered service. The Plan says that full mouth debridement is not listed as a covered service either.
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 tobacco counseling and full mouth debridement are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the tobacco counseling for the control and prevention of oral disease (D1320), and full mouth debridement (D4355) provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a single lens spectacle mounted low vision aid (Smartlux
digital electronic magnifying glass) provided on February 19, 2021.
You asked the Plan to pay for a single lens spectacle mounted low vision aid. You say that you have macular
degeneration in your eye, and you need to read better. The Plan denied your request. The Plan says the
Smartlux digital electronic magnifying glass is not a covered benefit. Additionally, the provider you used is not
in-network.
The Plan must follow Medicare rules. Medicare rules say Medicare does not pay for low vision aids. This
exclusion includes all devices that use one or more lenses to aid vision or magnify images.
We looked at the file and the Medicare rules. Medicare does not pay for low vision aids. This exclusion
includes all devices that use one or more lenses to aid vision or magnify images. Therefore, we decided that the
Plan does not have to pay for a single lens spectacle mounted low vision aid (Smartlux digital electronic
magnifying glass) provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Nebulizer (E0570) with sales tax
(S9999).
You asked the Plan to waive the copayment for a Nebulizer. You say that the services should be covered in full
The Plan denied your request. The Plan says the coinsurance applied correctly based on 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 20%
coinsurance for Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for a nebulizer (the allowed amount is $46.50, 20% of that is
$9.30), $9.30 + the sales tax ($8.40) = a total bill of $17.70. Medicare does not make separate payment for
sales tax. Nebulizers fall within the Durable medical equipment (DME) and related 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 a Nebulizer (E0570) with sales tax (S9999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, thorax, diagnostic; without contrast material
(CPT code 71250).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your
request. The Plan says there is no indication of why repeat CT was ordered. The Plan must follow Medicare
rules. Medicare rules say that CT scans are covered only when they are medically necessary.
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 CT scan. Our physician reviewer
found the record indicates that you had a CT scan in March 2021 that showed a 3 millimeters (mm) nodule
with recommendation for repeat in one (1) year. The provided records do not indicate the medical necessity or
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria
are not satisfied. The requested service cannot be recommended. 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 CT scan
have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan, thorax,
diagnostic; without contrast material (CPT code 71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 291 provided from May 2, 2020 to May 7, 2020.
You asked the Plan to pay for the inpatient hospital services with DRG 291. You say that the medical records support the billing of the secondary diagnosis code J96.01: Acute respiratory failure with hypoxia with DRG 291 The Plan denied your request. The Plan says the medical records do not support the billing of the secondary diagnosis code J96.01: Acute respiratory failure with hypoxia with DRG 291
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 inpatient hospital services with DRG 291. Our reviewer says that the medical records do not support the billing of the secondary diagnosis code J96.01: Acute respiratory failure with hypoxia with DRG 291. Our physician reviewer found the review indicates that the documentation supported an admission for Hypertensive Heart Disease with heart failure. The documentation was inconsistent regarding a diagnosis of acute respiratory failure. Even though acute respiratory failure was documented by the attending provider, supporting medical record documentation was not found within the record. The review indicates that the medical records did not support the billing of the secondary diagnosis code J96.01: Acute respiratory failure with hypoxia with DRG 291. 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 hospital services with diagnosis related group (DRG) 291 provided from May 2, 2020 to May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 18,
2020 to August 19, 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 submitted records do not support the billing of primary diagnosis code K85.90.
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 K85.90 (acute pancreatitis). 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 these services. Our reviewer says that the submitted records do not
support the billing of primary diagnosis code K85.90. Our physician reviewer found the submitted records
support the admission for further evaluation and treatment of hypertensive emergency in a patient with
underlying history, including end-stage renal disease (ESRD) with hemodialysis and hypertension. The
physical exam findings showed a soft, non-distended abdomen with diffuse tenderness and no rebound,
guarding or rigidity. Chest x-ray findings showed clear lungs with hilar areas and mediastinum intact without
pleural effusions. The medical record documentation was incomplete to reflect significantly elevated serum
amylase or lipase levels, abdominal pain consistent with acute pancreatitis, or abnormal imaging studies to
substantiate a diagnosis of pancreatitis.
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 hospital services rendered from August 18, 2020 to August 19,2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a comprehensive eye examination and an eye refraction provided on July 28, 2021.
You asked the Plan to waive the deductible for a comprehensive eye examination and an eye refraction. You say that the eye exam should be covered with a $0 balance. The Plan denied your request. The Plan says your deductible for this claim totaling $142.57 towards the $750.00 deductible amount, leaving the remaining deductible $607.43 for the Plan year.
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 $750 deductible for your covered medical services. You have been asked to pay $750 deductible for a comprehensive eye examination and an eye refraction.
The comprehensive eye examination and an eye refraction falls within the What is your Plan deductible 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 deductible for a comprehensive eye examination and an eye refraction provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the oral exam (D0120), prophylaxis (D1110),
and filling (D2331) provided on June 18, 2021.
You asked the Plan to pay the full amount for the dental services. You say that you were advised this provider
was in network. The Plan denied your request. The Plan says Medicare-covered dental services you receive out
of network have a 30% coinsurance that applies.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the provider in this case is out of network.
Additionally, the record shows that you did not make any calls to the Plan prior to the date of service to verify
the provider's network status. Therefore, we decided that the Plan does not have to pay the full amount for the
oral exam (D0120), prophylaxis (D1110), and filling (D2331) provided on June 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided
June 21, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you did not know an
ambulance was called and do not feel you should be responsible for the copayment. The Plan denied your
request. The Plan says you were charged this cost sharing 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 $325
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $325 for these
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 the ambulance services (A0429) provided June
21, 2021.