Persius/hicric huggingface dataset:
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's current status is unstable and critical. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital; there are no issues for which an LTACH may offer a therapeutic advantage.
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 record indicates that the enrollee is improving but still requires ongoing acute care services. The enrollee is receiving ongoing 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. The elements of the coverage rules 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 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 waive the copayment for the inpatient hospital services provided May 8, 2021, to May 14, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you expected cost-shares related to coronavirus (COVID-19) to be waived. The Plan denied your request. The Plan says as of April 1, 2021, cost-shares related to COVID-19 are no longer waived by the Plan. The copayment has been applied correctly to this claim.  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 copayment for each day for days 1 to 5 for Medicare-covered hospital care.  You have been asked to pay a total of $1,475 ($295 copayment x 5 days = $1,475) for the inpatient hospital services. The inpatient hospital services fall within the Inpatient hospital care 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 inpatient hospital services provided May 8, 2021, to May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI (70544) provided on July 30, 2021.
You asked the Plan to waive the copayment for the MRI. You say that the services should be covered as you did not have to pay a copayment before. The Plan denied your request. The Plan says the copayment 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 $110 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. You have been asked to pay a $110 copayment for an MRI. MRI's fall 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 an MRI (70544) provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electroencephalogram (EEG) analysis (95957) provided on
June 16, 2021.
You asked the Plan to pay for EEG analysis 95957. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because code
95957 has a procedure-to-procedure (PTP) edit of 0 with code 95718 so is not separately payable.
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, we have confirmed that code 95957
is a column II code to column I code 95718. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for electroencephalogram (EEG) analysis (95957) provided on June
16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ultrasounds provided on August 26, 2021.  You asked the Plan to waive the copayment for the ultrasounds. You say that the services should be covered, and you are unsure why the plan isn't covering them. The Plan denied your request. The Plan says the cost-sharing 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 $125 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.        You have been asked to pay a $107.43 copayment for the abdominal ultrasound and a $77.57 copayment for an elastography ultrasound, and both are less than the $125 each stated in the Plan's contract. Ultrasounds fall 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 ultrasounds provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete upper denture (D5110) provided on July 29, 2021.
You asked the Plan to pay for the dental item. You say that the provider advised they do not write off on
Premium dentures. You say that you signed an agreement saying you would pay $348 for the denture. You also
say that the provider will not refund you the difference. The Plan denied your request. The Plan says that there
is a member responsibility of $0.
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 follows these rules.
You were referred for the dental item by a contract provider. The file does not show that the Plan provided
notice that the dental item would not be covered. Under Medicare rules, this means the dental item is
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the complete upper denture
(D5110) provided on July 29, 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 physical therapy services provided by a physical therapy assistant on September 10, 2020.   You asked the Plan to pay for the physical therapy services. You say that the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on September 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76775) provided on September 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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, we have confirmed that code 76775
is a column II code to column I code 76770. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the services (76775) provided on September 17, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not have complex rehab needs.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not currently shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer
found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 24, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were referred out to several dentists and the receptionists did not inform you that the procedures would not be covered. You also say that you are on disability with limited income. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 19, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on August 19, 2021.
You asked the Plan to pay for the psychotherapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says there is no documentation of contact with the attending or primary care physician.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation.
We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on August 19, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scan of the head
(70544) provided on August 5, 2021.
You asked the Plan to pay for the MRA scan services. You say that you would like this claim reprocessed
based on the medical documentation. The Plan denied your request. The Plan says this claim has not been
billed with an appropriate modifier as required by Medicare rules.
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, we have confirmed that code 70544
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scan of the head
(70544) provided on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (CPT code 20939), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal surgery. More research is needed to show safety and efficacy. 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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the bone marrow aspiration for bone grafting, spine surgery only, through separate skin or
fascial incision (CPT code 20939), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper
or lower extremity arteries (93922) and testings of autonomic nervous system functions (95921 and 95923)
provided on January 21, 2021.
You asked the Plan to pay for the limited bilateral noninvasive physiologic studies and testings of autonomic
nervous system functions. The Plan denied your request. The Plan says Medicare does not cover Prolotherapy.
The Plan follows Medicare rules. Medicare rules say that services are deemed medically necessary when
specific conditions 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 pay for the limited bilateral noninvasive physiologic
studies and testings of autonomic nervous system functions. Our reviewer says that these services did not meet
the criteria for coverage. Our physician reviewer found the ordering physician did not have reasonable
expectation that their outcomes will potentially impact the clinical management of the patient. Our reviewer
found that the records do not show significant signs/symptoms of arterial or venous disease are present, nor
was the information necessary for appropriate medical and/or surgical management; nor was the test not
redundant of other diagnostic procedures that must be performed. Our physician reviewer also found that the
patient decided to follow-up as needed as treatment was not practical for her to continue. Testing did not lead
to change in treatment or outcome.
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 limited bilateral noninvasive physiologic studies and testings of autonomic
nervous system functions have not been met. Therefore, we decided that the Plan does not have to pay for the
limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) and testings of
autonomic nervous system functions (95921 and 95923) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation and non-spinal chiropractic
manipulative treatment provided on August 9, 2021.
You asked the Plan to pay for chiropractic services. You say that according to Medicare chiropractic
manipulative treatment is covered, and these codes have been paid in the past. The Plan denied your request.
The Plan says the denial of payment for these services is correct, because these services are not covered by
Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for electrical stimulation and non-spinal chiropractic manipulative treatment
provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 4, 6, 11, 13, 22, and 27.
You asked the Plan to pre-approve the endosteal implants. You say that these implants are medically necessary and urgently needed. The Plan denied your request. The Plan says implants were denied for tooth #'s 4, 6, 11, and 13 because the x-rays and records did not show that there is not enough bone to keep a denture in, or that there is an inability to retain a denture. The Plan also says that implants were denied for tooth #'s 22 and 27 because the records show that you have gotten a partial denture to replace these teeth within the past sixty (60) months or there was a recently approved a partial denture to replace this tooth.
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 endosteal
implants 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 pre-approve the endosteal implants. Our reviewer
says that given the presentation and documentation provided, the request for implants do not meet the Plan
criteria. Our physician reviewer found no documentation was provided as to the existing upper denture and any
issues that it may have presented and over what period of time. The lower arch reveals two lower canine teeth
with at least 50% remaining bone and a reported history of a lower partial denture having been made within the
last five years. Our reviewer found that in this instance there has not been any clear showing of there being
insufficient bone to retain a denture, or that there has been failed attempts to wear an upper denture over the
past two years. Our physician reviewer also found that the lower arch would not be eligible to be considered for
implants until two years had passed while attempting to wear a lower denture.
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 endosteal implants have not been met. Therefore, we decided that the Plan
does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 4,
6, 11, 13, 22, and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99100) provided on April 15, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based
on the medical documentation provided. The Plan denied your request. The Plan says separate payment is
never made for this claim according to Medicare rules.
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 99100 is anesthesia for patient of extreme age, younger
than 1 year and older than 70 (list separately in addition to code for primary anesthesia procedure).
We looked at the file and Medicare rules. Specifically, CPT code 99100 has a status indicator of B meaning
that payment for this service is always bundled into another procedure. Separate payment is not made for CPT
code 99100.Based on this information, we decided that Medicare rules for coverage of the anesthesia services
have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99100)
provided on April 15, 2021.