Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on September 17, 2021.
You asked the Plan to pay for the testing services. 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. In this case, the CPT Code Manual definition of code 76705 is ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up). We find that CPT code 76705 may be eligible for payment when billed with CPT code 93976. The code at issue was not billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered
experimental/investigational.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be
approved.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual psychotherapy session (90837) provided March 3, 2021 to March 29, 2021.
You asked the Plan to pay for the behavioral health services. You say that you are seeking reimbursement for the services. You were told this provider was out of network instead of not being a covered provider. You were told that the provider can call the Plan to receive retroactive approval. The Plan denied your request. The Plan says this type of provider is not part of the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The services were rendered by a licensed marriage and family therapist. Licensed marriage and family therapist are not eligible to participate in Medicare. Therefore, we decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual psychotherapy session (90837) provided March 3, 2021 to March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ankle foot orthotic (AFO) (L2114), 
provided on August 24, 2021. 
 
You asked the Plan to waive the copayment for the AFO. You say that the item should be covered. The Plan 
denied your request. The Plan says the cost share was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for durable medical equipment (DME) and related supplies.  
 
The enrollee has been asked to pay a 20% coinsurance for the AFO. the AFO falls within the durable medical 
equipment (DME) and related supplies 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 ankle foot orthotic (AFO) (L2114), 
provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from  
August 26, 2021, through September 24, 2021. 
 You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the 
continuation of SNF services was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain 
and for a fungal rash. Regarding rehabilitation services, the enrollee received physical therapy (PT) and 
occupational therapy (OT). By the dates in question, the enrollee was at a supervision to contact guard assist 
level with functional mobility including gait to 100 feet with a rolling walker. The enrollee required varying 
assist with activities of daily living. There were no identifiable skilled nursing service needs. There were no 
identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a 
daily basis. As a practical matter, the enrollee did not meet severity of illness or intensity of service criteria for 
an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of SNF services provided from August 26, 2021, through  
September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient admission provided from October 29, 2021, to November 1, 2021.
You asked the Plan to pay for the inpatient admission. You say that you do not see any reason why your stay in the hospital was not determined to be medically necessary. The Plan denied your request. The Plan says that the records do not indicate that the clinicians believed that at least two midnights in the hospital were expected. The Plan also says that the level of provided care could have been provided at a lower level of care though hospital outpatient observation
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. The Plan did not provide a copy of the applicable medical records for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of payment. Therefore, we decided that the Plan has to pay for the inpatient admission provided from October 29, 2021, to November 1, 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 pay for the inpatient psychiatric services provided from May 27,
2021, to June 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the inpatient psychiatric services. You say that the services provided were
medically reasonable and necessary for both the treatment of the enrollee's condition and on an inpatient
hospital basis. The Plan denied your request. The Plan says the services were rendered by a non-participating
provider, and there is no referring provider involved. The Plan also says that prior 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 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 inpatient psychiatric services provided from
May 27, 2021, to June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection (96374), provided on July 30, 
2021, through August 13, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that the cost share is wrong. The Plan 
denied your request. The Plan says the cost share was applied 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 $295 
copay for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $295 copay for the injection. the injection falls within the Outpatient Surgery 
and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 injection (96374), provided on July 30, 
2021, through August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on August 20, 2021.
You asked the Plan to pay for the hospital discharge day management (99238). You say that you are resubmitting the claim with medical records and the claim should be reviewed for payment. The Plan denied your request. The Plan says procedure code 99238 exceeds the allowed discharge per stay.
The Plan must follow Medicare rules. Medicare rules say that the E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay. In this case, the CPT Code Manual definition of code 99238 is hospital discharge day management; 30 minutes or less. We find that CPT code 99238 is not supported in the medical record. Specifically, CPT code 99238 was already billed on August 19, 2021, and paid for. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management (99238) have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on October 
22, 2021. 
 
You asked the Plan to pay for the maxillary partial denture. You say that you lost the two teeth that your 
previous partial clamped onto. You also say that you need this partial to be able to eat. The Plan denied your 
request. The Plan says your benefits for this service have been satisfied and the frequency limitation 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 Plans coverage rules apply in this case. 
 
 
 
 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, partial dentures are limited to one 
upper and/or one lower partial denture every five years. The record shows that you received a maxillary partial 
denture (D5213) on March 15, 2019 and your maxillary partial denture benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on October 
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet injections.
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 facet injections are covered when specific criteria are met. 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 you have chronic back pain.
It is noted that you have radicular symptoms and spinal stenosis, in additional to multi-level facet cause of your pain. The criteria for coverage are not met, as you have other probable pain generators noted. The facet injections are not medically necessary. 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 therapeutic facet injections.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee developed acute respiratory failure in setting of a stroke during the 
hospitalization. The enrollee is improving but still requires acute care services and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility.  
 
 
 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 9, 2021.
You asked the Plan to pay for the prophylaxis. You say that you have been treated for periodontal disease for
many years by getting your teeth cleaned four times per year. You also say that you would appreciate it if this
denial of payment could be rescinded. The Plan denied your request. The Plan says prophylaxes are payable
twice per calendar year.
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, you are limited to two cleanings per
year. The record shows that you received cleanings on January 12, 2021, and May 4, 2021 and your cleanings
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis
(D1110) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 5, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that the labs were ordered as part of your annual physical and should be paid in full. 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 $10 copayment for laboratory tests that are not a fecal immunochemical test (FIT) test. The record shows your laboratory services were not done at your annual physical office visit. You have been asked to pay a $10 copayment for laboratory services.
Laboratory services 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 laboratory services provided on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
July 20, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the device was medically 
necessary. The Plan denied your request. The Plan says this device was used while the enrollee was an 
inpatient and is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography, bilateral, including computer-
aided detection (CAD) when performed (77063) screening digital breast tomosynthesis, bilateral (list separately 
in addition to code for primary procedure) (77063) provided October 1, 2021.  
You asked the Plan to pay for the screening mammography. You say that you are disputing the denial of this 
claim as this will cost you $381.00 and this should be covered under your preventative services. The Plan 
denied your request. The Plan says the maximum benefit has been exhausted. 
 
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. 
 
A breast cancer screening is limited to one baseline mammogram every 12 months. The records show that this 
service was already provided on date of service September 17, 2021 and payment was approved by the Plan. 
Since the Plan has paid for a previous screening mammogram, no additional payments can be made. Therefore, 
we decided that the Plan does not have to pay for screening mammography, bilateral, including computer-aided 
detection (CAD) when performed (77063) screening digital breast tomosynthesis, bilateral (list separately in 
addition to code for primary procedure) (77063) provided October 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a diagnostic mammogram 
provided on October 29, 2021. 
 
You asked the Plan to waive the deductible and copayment for a diagnostic mammogram. You say that you 
thought you were having your annual mammogram. You said that your order form had diagnostic written on it, 
and you were told it would prevent an unnecessary return visit. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible for in-network services. Your contract also says there 
is a $10 copayment for x-rays. 
 
You have been asked to pay $49.23, which was the remaining amount of your in-network deductible. Your 
deductible has now been fully met. 
 
You have also been asked to pay a $10 copayment for the mammogram. After your deductible is met, you must 
also pay the applicable copayment toward any remaining allowed amount. Diagnostic mammograms fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $300 deductible and a $10 copayment which 
applies to in-network x-ray services, including diagnostic mammograms. This cost sharing is a contractual 
obligation that had not been met at the time a diagnostic mammogram was received on October 29, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible and copayment for a diagnostic 
mammogram provided on October 29, 2021.