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

We decided that the Plan does not have to waive the copayments for the dermatology visits you had on August 27, 2021, and September 17, 2021.
You asked the Plan to waive the copayments for the dermatology visits. You say that you went to the doctor's office to have a squamous cell carcinoma removed from your back. You stated that you had to return a few weeks later because it grew back in the same spot. You do not believe you should have to pay copayments for this since you were told that the carcinoma had been removed. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for specialist services.
You have been asked to pay a $40 copayment per visit for the dermatology visits. These copayments apply for each visit, regardless of the reason for the visit. 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 dermatology visits you had on August 27, 2021, and September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiology genetic panel (81479) provided on October 9, 2020.
You asked the Plan to pay for a cardiology genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a cardiology genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiology genetic panel (81479) provided on October 9, 2020
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient psychiatric admission provided from May 17, 2021,
through May 25, 2021.
You asked the Plan to pay for inpatient psychiatric hospital services. You say that an inpatient psychiatric
admission was medically necessary. The Plan denied your request. The Plan says that an inpatient psychiatric
admission was not medically necessary.
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 pay for inpatient psychiatric hospital services. Our
reviewer says that the inpatient psychiatric hospital services were medically necessary. Our physician reviewer
found that based upon review of the records provided it was expected this enrollee would improve in a
reasonable period of time as although he did not have dangerousness to self or others. This enrollee did have
auditory no visual hallucinations, delusions and was showing behavioral issues. It did appear medically
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a
lower level of care as although he did not have dangerousness to self or others, perceptual disturbance
including delusions. He did have auditory no visual hallucinations and delusional thinking. The health Plan's
denial of inpatient psychiatric services appears inappropriate. This enrollee did appear to require inpatient
mental health treatment as although he was not a danger to himself or others, he was angry and hostile. It did
appear that active treatment was taking place. It did appear that the services were reasonably expected to
improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized
treatment plan however the entire record is not present. It did appear that the records were supervised and
evaluated by a physician. Based upon review the records provided, for the admission of this enrollee does meet
the criteria for acute inpatient mental health treatment as although this enrollee was not shown to be a danger to
himself or others, he was showing agitation and aggression with perceptual disturbance including auditory no
visual hallucinations and delusions.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided
that the Plan has to pay for an inpatient psychiatric admission provided from May 17, 2021, through
May 25, 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 first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), two dimensional (2D) oral/facial photographic images (D0350), topical application of fluoride varnish (D1206), and oral hygiene instructions (D1330) provided on August 11, 2021.
You asked the Plan to pay for the intraoral periapical x-rays, 2D oral/facial photographic image, topical application of fluoride varnish, and oral hygiene instructions. You say that you were told that these charges would be paid by the Plan. The Plan denied your request. The Plan says these services are not covered expenses 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 first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), two dimensional (2D) oral/facial photographic images (D0350), topical application of fluoride varnish (D1206), and oral hygiene instructions (D1330) provided on August 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 provided on May 14, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
We find that CPT code 99214 is not supported in the medical record. Specifically, the professional component
must be billed separately. Based on this information, we decided that Medicare rules for coverage of the office
visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded
99214 provided on May 14, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment to a nursing home provided on July 7, 2021, billed with code R0070.
You asked the Plan to pay for the services as billed. You say that this should be paid since it is associated with radiology billed on another claim. The Plan denied your request. The Plan says this is not payable as billed since it was not billed with radiology services or the set-up charges.
The Plan must follow Medicare rules. Medicare rules say that transportation for portable x-ray services is billed using R0070 or R0075 and must be billed in conjunction with the radiology codes. This was billed on a separate claim without the radiology codes and without a set-up charge. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment to a nursing home provided on July 7, 2021, billed with code R0070.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) provided on May 21, 2021.
You asked the Plan to pay for a wig. You say that the item at issue is a medical necessity for you. The Plan
denied your request. The Plan says the item at issue is not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282)
provided on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. 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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 4, 2021, to June 18, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says that the acute inpatient hospital admission was not medically necessary.
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 indicates that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 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 June 4, 2021, to June 18, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on April 19, 2021.
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. 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 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. We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have status codes of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set coded S1015 and the infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the need was not met because anesthesia is already included with this procedure code and does not need to be billed separately.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that according to the anesthesiology record, the enrollee has a diagnosis of obesity with a BMI of 43.9. However, the submitted medical records did not support a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of sedation/anesthesia services/monitored anesthesia care. There is nothing in the enrollee's record indicating that it was medically necessary to have an anesthesiologist present during the epidural steroid injection.
The review has determined that the anesthesia for diagnostic or therapeutic nerve blocks is not indicated. The requested anesthesia service is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services provided on July 14, 2021.
You asked the Plan to pay for the services provided. You say that the qualifying services were billed. The Plan denied your request. The Plan says the provider did not report setup codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. We find that the x-ray services were not reported correctly. Specifically, the claim does not show that a set-up component was billed for the services at issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the portable x-ray services provided on July 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up office visit provided on June 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were not urgent nor emergent in nature and were not approved in advance, therefore, the Plan does not have to pay for the services.
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 a follow-up office visit provided on June 2, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (93000) provided on August 5, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $30 copayment for Medicare-covered non-radiological diagnostic services. You have been asked to pay $16.38 for the Medicare-covered non-radiological diagnostic service provided. This is the Plan's allowed amount for this service which is less than the applicable copayment.
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 electrocardiogram (93000) provided on
August 5, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits (99213) provided on
May 22, 2020 and June 12, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
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 $35
copayment for each Medicare-covered outpatient mental health visit.
You have been asked to pay $70 ($35 copayment x 2) for the Medicare-covered outpatient mental health visits
provided. 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 office visits (99213) provided on May 22,
2020 and June 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a
participating provider on June 4, 2021, to July 21, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you do not feel like you should
be responsible for this. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $40
copayment for outpatient rehabilitation services/in-network.
You have been asked to pay a $40 copayment for physical therapy. The total amount you are being asked to
pay is $440 ($40 x 11 visits = $440). The correct copayments have been applied to the physical therapy that
was provided. Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on June 4, 2021, to July 21, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on March 30, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is not supported in the documentation.
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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (e.g., humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).
We find that CPT code 29823 is not supported in the medical record. Specifically, the records do not show that the code accurately describes the services that were provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services provided on March 30, 2021.