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

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on January 8, 2020.
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan denied your request. The Plan says the original claim was submitted without a ZIP code for the pick up address. The Plan says that a corrected claim was submitted and was still missing this information. The Plan also says that the corrected claim was not submitted until after the 12-month filing timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance services was not filed until August 6, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical implant (D6010), porcelain/ceramic crown (D6058), maxillary partial denture (D5213), and a ceramic crown (D6059) provided by an out-of-network provider.
You asked the Plan to pre-approve a surgical implant, porcelain/ceramic crown, maxillary partial denture, and a ceramic crown. You say that you believe these services are medically necessary. The Plan denied your request. The Plan says these services are not covered with 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical implant (D6010), porcelain/ceramic crown (D6058), maxillary partial denture (D5213), and a ceramic crown (D6059) provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from May 28, 2021, to June 8, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you were told you would not have to pay anything for your stay. The Plan denied your request. The Plan says you have been asked to pay 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 $370 copayment for each day for days 1 to 5 for in-network Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days.
You have been asked to pay a $370 copayment for each day, days 1 to 5 for the inpatient hospital admission. ($370 x 5 = $1,850). The inpatient hospital admission falls within the "Inpatient Hospital Care" benefit category. The record shows you were seen at an inpatient rehabilitation hospital.
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 admission provided from May 28, 2021, to June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from September 23, 2020 to September 30, 2020.
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the file shows inconsistencies between the documentation in the medical records and the PDPM score billed. 5-day MDS assessment was not received with requested medical records. The ARD is unknown and controls payment for September 23, 2020 to September 30, 2020. The provider billed PDPM score KAPD1 x 7 days. It is impossible to determine if the documentation supports the billed PDPM score without a valid ARD date and MDS assessment. Documentation to support all of Section GG payment items is needed. The Functional Abilities Section GG report cannot be used to validate GG items as signature of completion is missing. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from September 23, 2020 to September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 7, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
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 the denied codes is: CPT 87486: Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique CPT 87496: Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique
CPT 87498: Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed CPT 87541: Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique CPT 87581: Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique CPT 87631: Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets CPT 87640: Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique CPT 87798: Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism Healthcare Common Procedure Coding System (HCPCS) J7321: Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose HCPCS J7326: Hyaluronan or derivative, gel-one, for intra-articular injection, per dose We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the gynecology visit and the transvaginal ultrasound you had on March 27, 2021.
You asked the Plan to waive the copayments for the gynecology visit and the transvaginal ultrasound. You say that this was a preventative visit and you have had this test in the past with a much lower copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that in relation to the office visit, you received diagnostic services in addition to preventive services, so that is why the specialist office visit copayment applies.
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 diagnostic radiology services and a $45 copayment for specialist visits.
You have been asked to pay a $45 copayment for the gynecology visit and a $125 copayment for the transvaginal ultrasound. The medical records show that in addition to preventive services, you were also evaluated for stress incontinence and a leiomyoma of the uterus. These evaluations are not part of any preventive visit, so that is why the specialist office visit copayment applies. In addition, the transvaginal ultrasound falls within the diagnostic radiology 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 copayments for the gynecology visit and the transvaginal ultrasound you had on March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 29, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 29, 2021.
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 June 24, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were referred to
this provider and were not aware they were out-of-network. The Plan denied your request. The Plan says this
service is not specifically excluded from 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
problem focused limited oral evaluation (D0140) provided on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for posterior segmental instrumentation (22842) and autograft (20936) provided on April 5, 2021.
You asked the Plan to pay for posterior segmental instrumentation and autograft. You say that you are appealing with records for review. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the record does not support code 22842 and code 20936 is always bundled for payment.
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 state that code 20936 is always bundled for payment and if it is covered the payment for it is subsumed by the payment for services to which it is incident. In this case, the CPT Code Manual definition of code 22842 is posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (list separately in addition to code for primary procedure). We asked our coder 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 posterior segmental instrumentation and autograft. Our reviewer says that code 22842 does not meet the criteria for payment. Our reviewer found the operative report does not document the segments that this procedure was performed on. The vertebral segments cannot be confirmed due to the location of placement was not documented in the operative report. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of posterior segmental instrumentation and autograft have not been met. Therefore, we decided that the Plan does not have to pay for posterior segmental instrumentation (22842) and autograft (20936) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal (D6240) and a retainer crown (D6750) provided by a participating provider.
You asked the Plan to pre-approve a porcelain fused to high noble metal and a retainer crown. You say that you would like these services approved. The Plan denied your request. The Plan says these services are not medically necessary.
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 a porcelain fused to high noble metal and a retainer crown when the services are medically necessary and reasonable. 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 a porcelain fused to high noble metal and a retainer crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to high noble metal (D6240) and a retainer crown (D6750) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 4, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you need continued psychiatric care at the inpatient level. The Plan denied your request. The Plan says as of November 4, 2021, you no longer meet the criteria for coverage of inpatient psychiatric care. You can be stepped down to a less restrictive level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the Plan's denial of continued psychiatric services at the inpatient level is appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on October 28, 2021 with Major Neurocognitive Unspecified with Behavioral Disturbance. Based upon review the records provided it was not expected that you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You did not show any abnormal behaviors or any symptoms which would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to self or others and were compliant with treatment. It does not appear that active treatment was taking place beyond the date in question. It does not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Based upon a review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 4, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive behaviors or required treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 4, 2021, onward.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity studies provided on February 25, 2021.
You asked the Plan to pay for the testing services. You say that these were the only acceptable codes. 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.
We looked at the file and the rules. We find that CPT code 93990 was billed with codes 93922 and 93925. The
code combinations may be eligible for payment. However, the provided claim does not show that the services
were 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 extremity studies provided on February 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation.
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need transportation to get to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 65 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of a home health or hospice aide (G0156) provided on June 1, 2021, through June 11, 2021.
You asked the Plan to pay for the services of a home health or hospice aide. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes. We asked our coder 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 services of a home health or hospice aide. Our reviewer says that CPT code G0156 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not include home health aide documentation. The physician notes and certification for home health and plan of care do not support that home health/hospice aide services were performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services of a home health or hospice aide have not been met. Therefore, we decided that the Plan does not have to pay for the services of a home health or hospice aide (G0156) provided on June 1, 2021, through June 11, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit and self-administered drugs provided on March 13, 2021.
You asked the Plan to pay for emergency room visit and self-administered drugs. You say that you are appealing this claim. The Plan denied your request. The Plan says the copayment amount you are being charged is correct and the denial of payment for self-administered drugs is correct.
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 rules say that Medicare Part B generally does not pay for self-administered drugs. Your contract with the Plan clearly says that you must pay $90 copayment for emergency care. You have been asked to pay $90 copayment for emergency room visit. Emergency room visit and self-administered drugs 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. Additionally, the self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for an emergency room visit and self-administered drugs provided on March 13, 2021.