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 with diagnosis related group
371 provided from June 5, 2020 to June 9, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the
billing of the secondary diagnosis code D61.810: Antineoplastic chemotherapy induced pancytopenia with
DRG 371. The Plan denied your request. The Plan says the medical records do not support the billing of the
secondary diagnosis code D61.810: Antineoplastic chemotherapy induced pancytopenia with DRG 371.
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 D61.810. 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. Our reviewer says that the medical records do not
support the billing of the secondary diagnosis code D61.810: Antineoplastic chemotherapy induced
pancytopenia with DRG 371. Our physician reviewer found the enrollee was admitted on June 5, 2020 for
weakness. The history, physical exam, progress notes, prescription plan and discharge summary does not
support Pancytopenia. DRG 371 is not the most appropriate code to use for the services provided.
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 371 provided from June 5, 2020 to June 9, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (R0070) provided June 16, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim was not billed with a valid place of 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.
We find that CPT code R0070 is not supported in the medical record. Specifically, the billed code has a
Professional Component / Technical Component indicator of 3. The service was not billed with an inpatient
place of service. Based on this information, we decided that Medicare rules for coverage of the radiology
services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services
(R0070) provided June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for pathology services provided to the enrollee on June 15, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this tissue was taken from a tooth during a general dental service and sent for pathology. The Plan contract states that supplemental dental services are not covered for this enrollee.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for pathology services provided to the enrollee on June 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425) provided November 11, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 256 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425) provided November 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on August 25,
2021, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the requested services were a necessity for
the enrollee's care. The Plan denied your request. The Plan says rules for out-of-network care have not been
met.
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 psychotherapy services (90832) provided on
August 25, 2021, by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
August 11, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you thought your insurance
would cover two cleanings per year and x-rays one a year. You also say that you were not asked if you wanted
these x-rays, nor did you object because you thought it was normal. The Plan denied your request. The Plan
says this service is not a covered expense under your dental plan. The Plan also says that you did not contact
the Plan prior to the date of service to verify benefits.
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
complete series of intraoral x-rays (D0210) provided on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 4, 2021, through February 10, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that these services have been denied due to failure to follow the Plan's contractual notification requirements.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 4, 2021, through February 10, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on June 30, 2021 by a
Medicare opt out provider.
You asked the Plan to pay for the periodontal maintenance. You say that your insurance has paid for this
service in the past. The Plan denied your request. The Plan says you received these services from a provider
who chose not to receive Medicare funds. The Plan also says that if you use a provider that has opted out of
Medicare, you will not receive reimbursement.
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
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodontal maintenance provided on June 30, 2021 by a Medicare opt out
provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and cone beam computed tomography (CT) capture and interpretation provided on June 7, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and cone beam CT capture and interpretation. You say that you were led to believe this provider was in-network. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says payment cannot be issued for services rendered by a provider who has opted out of Medicare.
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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and cone beam computed tomography (CT) capture and interpretation provided on June 7, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on August 20,
2021.
You asked the Plan to pay for the resin-based composite. You say that you do not have dental insurance and are
on social security. You also say that you would like this charge to be waived. The Plan denied your request.
The Plan says this service is not a covered benefit. The Plan also says that prior to receiving this service you
were advised that the filling would not be covered, and you would be responsible to pay for the service.
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 resinbased
composite (D2392) provided on August 20, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425) provided on June 13, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied
your request. The Plan says that the enrollee's claims history indicates they were in an inpatient hospital status
on this date of service. Ambulance services used for the transportation of a hospital inpatient to another facility
for diagnostic tests or special treatment for example is considered part of the inpatient admission, and not
separately payable.
The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is
considered "patient transportation" and is covered as an inpatient hospital service.
We looked at the file and the Medicare rules. In this case, the documentation has determined the enrollee was
transported to another facility temporarily for care. This is not separately payable from the inpatient services
according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the
ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for
ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on June 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage (A0425) provided July 26, 2021.
You asked the Plan to waive the copayment for the ambulance services and transport. You say that you did not want to take the ambulance transport. The Plan denied your request. The Plan says the copayment 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 $210 copayment for covered one-way ground ambulance services. You have been asked to pay a $210 copayment for the ambulance services and transport. The ambulance services and transport fall within the Ambulance services 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 ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage (A0425) provided July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV).
You asked the Plan to pre-approve a POV. You say that the requested POV is medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet criteria for the requested POV.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 a POV. Our reviewer says that the
enrollee does not meet criteria for the requested POV. Our physician reviewer found the enrollee has a mobility
deficit. The enrollee is able to ambulate short distances but is impaired due to not having an ankle-foot orthosis
(AFO). The enrollee was told he needs to receive his AFO and have his ambulatory ability assessed again to
see if he meets the criteria for a power wheelchair. It is not clear that the enrollee's mobility deficit requires a
power wheelchair at this time without a reassessment after the AFO. It is not clear that a power wheelchair will
significantly improve mobility related activities of daily living participation in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does not have to
pre-approve a power operated vehicle (POV).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 8, 2021.
You asked the Plan to pay for the surgical extraction. You say that you asked the Plan to cover the extraction and were told it would be covered, but it was not. The Plan denied your request. The Plan says extractions are not a covered benefit under your plan. The Plan also says that the extraction was previously requested under a pre-service review, and the service was denied due to no plan coverage.
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 surgical extraction (D7210) provided on April 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound of the heart (93306) and
office visit with a specialist (99214) provided on June 16, 2021, and June 22, 2021.
You asked the Plan to waive the copayments for the ultrasound and office visit. You say that you feel your
insurance should be paying more for these services. The Plan denied your request. The Plan says the cost-
sharing for these services was applied in accordance with your contract.
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 $160
copayment for Medicare-covered radiological diagnostic services other than x-rays and a $30 copayment for an
office visit with a specialist.
You have been asked to pay a $160 copayment for the ultrasound and a $30 copayment for the office visit. The
ultrasound falls within the Medicare-covered radiological diagnostic services other than x-rays benefit
category, and the office visit was provided by a cardiologist. 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 copayments
for the ultrasound of the heart (93306) and office visit with a specialist (99214) provided on June 16, 2021, and
June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the core build up (D2950) provided on December
17, 2020.
You asked the Plan to reimburse you for the core build up. You say that the provider was supposed to get
authorization for the services. You say that you paid $1,400 out of pocket. You also say that you should be
reimbursed. The Plan denied your request. The Plan says core build up is not a covered service.
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 core build up is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the core
build up (D2950) provided on December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services coded 75705 provided on April 1, 2021.
You asked the Plan to pay for the angiography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 75705 for the angiography services is a column II code to column I code 37243. 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 angiography services coded 75705 provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DecisionDx-Melanoma testing (CPT code 81529) provided to the enrollee on July 20, 2021.
You asked the Plan to pre-approve the testing. You say that this should be a covered benefit for the enrollee based on Medicare's Local Coverage Decision MOLDX: Melanoma Risk Stratification Molecular Testing (L37725). The Plan denied your request. The Plan says the guidelines you quoted in the appeal are not a part of this enrollee's Medicare Administrative Contractor (MAC). The Plan states the test has not been validated and proven to improve clinical outcomes, it has not been proven beneficial to enrollee care. The Plan states there are currently no clinical studies that have determined whether the results of the DecisionDx-Melanoma can be used to direct future care, treatment, or testing in this clinical scenario.
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 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided and current clinical guidelines there is no documentation that the DecisionDx-Melanoma testing at issue in this case meets Medicare criteria for medically reasonable and 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 pre-approve DecisionDx-Melanoma testing (CPT code 81529) provided to the enrollee on July 20, 2021