Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) imaging services.

You asked the Plan to pre-approve the PET scan. You say that the records provided support the need for the requested PET scan. The Plan denied your request. The Plan says that the requested PET scan does not fit medical necessity guidelines. The Plan says that other tests should be performed first to support the need for the PET scan.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has a diagnosis of abnormal results of liver function studies. On July 12, 2021, a computed tomography (CT) scan angio of the chest, abdomen, and pelvis demonstrated an unusual lobulated heterogeneous apparently hyper-enhancing 34mm left retroperitoneal mass. The differential diagnosis includes a broad differential diagnosis of benign and malignant lesions. The radiologist suggested correlation with a PET/CT scan initially. A PET scan can be covered at this time, as the enrollee has a solid tumor that is strongly suspected based on other diagnostic testing. A PET scan is considered medically reasonable and necessary in this case. 

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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) imaging services.

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on April 7, 2021.  You asked the Plan to pay for the outpatient hospital services. You say that you would like this claim reprocessed as the enrollee did not need to be admitted inpatient for the services rendered. The Plan denied your request. The Plan says this claim has not been billed in accordance with Medicare coding regulations.  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 60650 is laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Specifically, code 60650 has a Payment Status Indicator of "C" meaning that it is an Inpatient Only Procedure. Payment cannot be made for this service performed as an outpatient procedure. Furthermore, the entire claim is denying based on an OCE edit. Based on the OCE, all claim line items that have been billed on this claim will be denied because they are services being billed on an outpatient claim form concurrently with a code that has a Payment Status Indicator of "C". Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation care discharge day management (99217) provided on September 28, 2021.  

You asked the Plan to pay for the observation care discharge day management. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed in accordance with 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 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the observation care discharge day management have not been met. Specifically, this claim was not billed with a qualifying initial observation care code. Therefore, we decided that the Plan does not have to pay for the observation care discharge day management (99217) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services rendered on July 9, 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 99152 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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.  We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of the presence of an independent trained observer to monitor the patient's level of consciousness and physiological status, first 15 minutes. 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 moderate sedation services rendered on July 9, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the influenza and pneumonia vaccine. We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap).

You asked the Plan to pay for the immunizations. You say that these were necessary vaccines as prescribed by your doctor. The Plan says that the claim was not billed correctly.

We decided that the Plan has to pay for the influenza and pneumonia vaccine.

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. The plan also has rules stating that the pneumonia vaccine and appropriate flu shots are covered. 

The case file appears to show that your doctor, who is a contract provide with the plan, referred you to the vaccines that are denied in this case. The plan contract explicitly covers the pneumonia and influenza vaccine. You would have every right to believe that these vaccines would be covered. Based on this information, we decided that Medicare rules for coverage of the influenza and pneumonia vaccine have been met. Therefore, we decided that the Plan has to pay for the influenza and pneumonia vaccine.

We also decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap).

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to this specific vaccine. This is not listed as a covered shot in your plan contract. Based on this information, we decided that Medicare rules for coverage of the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) have not been met. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap).

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on August 6, 2021 to August 29, 2021 by an out-of-network (OON) provider.  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 services were rendered by an out-of-network provider without prior authorization.  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 the outpatient hospital services provided on August 6, 2021 to August 29, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered screening test.  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.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 31, 2021.
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 appears to be more stable but requires additional short-term acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.    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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services provided on July 2, 2021.
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the services should be covered. 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 $25 copayment for Outpatient Mental Health Care.
You have been asked to pay a $25 copayment for outpatient mental health 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 outpatient mental health services provided on July 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the swallowing function evaluation (92611) provided on September 1, 2021.
You asked the Plan to pay for the swallowing function evaluation (92611). You say that per national coding edits and CMS guidelines no modifier is required for CPT code 92611. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says the claim must include a therapy modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that providers/suppliers must continue to report one of the modifiers for any therapy code on the list of applicable therapy codes. In this case, the CPT Code Manual definition of code 92611 is motion fluoroscopic evaluation of swallowing function by cine or video recording. We find that CPT code 92611 is not supported in the medical record. Specifically, CPT code 92611 is considered a therapy code. This means that CPT code 92611 requires a therapy modifier of GN, GO or GP. The claim shows that CPT code 92611 was not billed with a required therapy modifier. Based on this information, we decided that Medicare rules for coverage of the swallowing function evaluation (92611) have not been met. Therefore, we decided that the Plan does not have to pay for the swallowing function evaluation (92611) provided on September 1, 2021.
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 appears to be gradually improving, however, there is still need for additional short-term acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on August 31,
2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says the services do not meet coverage requirements.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there was no documented result of prior prostate biopsy. There was no documented significant interval
increase in prostate-specific antigen (PSA) level. The review has determined that the services at issue in this
case were not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have
to pay for the SelectMDx test provided to the enrollee on August 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services received on
August 17, 2020.
You asked the Plan to waive the copayment for the services. You say that you did not receive any medical
services on August 17, 2020 or any other time. The Plan denied your request. The Plan says you left against
medical advice, which is not a reason for a refund of copayment.
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 room care.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
October 6, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you should not be responsible for the
copayment due to your negative experience at the ER. 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 $90
copayment for each emergency room visit. 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit
provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 22, 2021.  You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the office advised you that the hygienist will not clean your teeth unless the hygienist can do a once-a-year periodontal exam. You also say that the hygienist does not have the proper training to do a periodontal exam and you feel that you should not have to pay $50.00 for that service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures (D5120 and D5110), comprehensive oral evaluation (D0150), and panoramic radiographic image (D0330), provided on October 13, 2021, by an out-of-network provider.

You asked the Plan to pay for the routine dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says you obtained these services out-of-network.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dentures (D5120 and D5110), comprehensive oral evaluation (D0150), and panoramic radiographic image (D0330), provided on October 13, 2021, by an out-of-network provider.