Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an intraoral x-ray (D0210), prophylaxis (D1110), a comprehensive oral evaluation (D0150), and an extraction (D7210) provided by a participating provider on June 9, 2021, to August 16, 2021.  You asked the Plan to waive the coinsurance for an intraoral x-ray, prophylaxis, a comprehensive oral evaluation, and an extraction. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says the correct coinsurance has 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 20% coinsurance and a 50% coinsurance for dental option/class 2 basic services and dental option/class 3 major services.   You have been asked to pay a 20% coinsurance for an intraoral x-ray, and a 50% coinsurance for extraction. There is a $0 copayment for a comprehensive oral evaluation and prophylaxis.   Date of Service CPT Code Allowed Amount Coinsurance Total Amount January 9, 2021 D0210 $99.60 20% $19.92 January 9, 2021 D0150 --- --- Covered Service January 9, 2021 D1110 --- --- Covered Service January 10, 2021 D2332 $194.52 20% $38.90 July 22, 2021 D7210 $473.16 50% $236.58 August 16, 2021 D7210 $236.58 50% $118.29  Total Amount You Are Being Asked to Pay: $19.92 + $38.90 + $236.58 + $118.29 = $413.69  An intraoral x-ray, prophylaxis, a comprehensive oral evaluation, and an extraction falls within the dental option/class 2 basic services and dental option/class 3 major 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 coinsurance for an intraoral x-ray (D0210), prophylaxis (D1110), a comprehensive oral evaluation (D0150), and an extraction (D7210) provided by a participating provider on June 9, 2021, to August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a walker (E0143) provided on July 13, 2021.  You asked the Plan to waive the coinsurance for the walker. You say that the services should be covered as you didn't have a choice receiving the walker. The Plan denied your request. The Plan says the coinsurance applied correctly based on the item 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 20% coinsurance for Durable medical equipment (DME) and related supplies.        You have been asked to pay a 20% coinsurance for a walker (the allowed amount is $85.69 x 20% = $17.13). Walkers fall within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a walker (E0143) provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Life Vest (K0606) provided on August 28, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the Life Vest. You say that you would like reconsideration because you were not aware that prior authorization was required. The Plan denied your request. The Plan says this service was not urgent, emergent or approved in advance.  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 Life Vest (K0606) provided on August 28, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services coded 76770 provided on September 21, 2021.  You asked the Plan to pay for the ultrasound 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 76770 is a column II code to column I code 93976. 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 ultrasound services coded 76770 provided on September 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency ambulance transport services coded A0428 and the ground mileage coded A0425 provided on August 15, 2021.  You asked the Plan to pay for the non-emergency ambulance transport services and the ground mileage. 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.  We find that CPT codes A0428 and A0425 are not supported in the medical record. Specifically, these codes were billed with primary/first-listed diagnosis of G46.4 (cerebellar stroke syndrome). There is a "code first" note which states that a code first underlying cerebrovascular disease code must be billed as the primary/first-listed code.  This means the appropriate primary or first listed code was not billed with these services. Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance transport services and the ground mileage have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport services coded A0428 and the ground mileage coded A0425 provided on August 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical or manipulative therapy performed for maintenance rather than restoration (S8990) provided on June 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that you have found an effective and reasonable priced chiropractor and his treatments are helpful in keeping your chronic back issues under control. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider.   The plan says if an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider.  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 physical or manipulative therapy performed for maintenance rather than restoration (S8990) provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and additional intraoral periapical x-ray (D0230) provided on August 16, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation and additional intraoral periapical x-ray. You say that you received two x-rays but were not advised of the cost or told that only one x-ray was covered. You also say that you do not believe an evaluation was provided and you were not allowed to thoroughly read through the paperwork you were asked to sign. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered expense under your dental plan. The Plan also says that your benefits for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on August 16, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and additional intraoral periapical x-ray (D0230) provided on August 16, 2021.   Your complaint about the treatment rendered by the provider and being billed more is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient surgery provided from July 12, 2021, to July 19, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that you have a cardiac murmur diagnosis which covers your services at $0.00 copayment for hospitalizations. 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 $175 copayment for outpatient surgery at an in-network outpatient hospital.   You have been asked to pay a $175 copayment for the outpatient surgery. The outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were considered an outpatient. 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 surgery provided from July 12, 2021, to July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an in-network provider on September 21, 2021, to September 23, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you think that the Plan should pay for this. The Plan denied your request. The Plan says the correct copayment has 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 $298 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $298 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care/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 an inpatient hospital stay provided by an in-network provider on September 21, 2021, to September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 2, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 2, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 pre-approve inpatient psychiatric care from February 2, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 2, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond February 2, 2022, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  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 care from February 2, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 2, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on December 15, 2020.  You asked the Plan to pay for the physician's services. You say that this was a follow-up visit from surgery and should not need an authorization for this visit to be covered. The Plan denied your request. The Plan says an authorization was required.  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 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 physician's services provided on December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the partial excision of tibia (27640), the partial excision of ankle/heel (28120) and bone graft (20902) provided on April 8, 2021.  You asked the Plan to pay for the partial excision of tibia (27640), the partial excision of ankle/heel (28120) and bone graft (20902). You say that you are resubmitting the claim with medical records that should be reviewed for payment. The Plan denied your request. The Plan says CPT code 27640 and 28120 are considered inclusive to CPT code 27870. The Plan also says that CPT code 20902 is not supported by the medical records submitted.  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 27640 is partial excision (craterization, saucerization, or diaphysectomy), bone (e.g., osteomyelitis); tibia. The CPT Code Manual definition of code 28120 is partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or bossing), talus or calcaneus. The CPT Code Manual definition of code 20902 is bone graft, any donor area; major or large.  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 partial excision of tibia (27640), the partial excision of ankle/heel (28120) and bone graft (20902). Our reviewer says that this does not meet the criteria for coverage. Our reviewer found that the operative report does not include documentation to support modifier -59 for CPT code 27640 and 28120. These procedures would be inclusive to CPT code 27870. For CPT code 20902, the operative report does not document a bone graft was obtained through separate incision.   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 partial excision of tibia (27640), the partial excision of ankle/heel (28120) and bone graft (20902) have not been met. Therefore, we decided that the Plan does not have to pay for the partial excision of tibia (27640), the partial excision of ankle/heel (28120) and bone graft (20902) provided on April 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device (22854) provided on September 7, 2021.  You asked the Plan to pay for the insertion of intervertebral biomechanical device (22854). You say that a separate plate was placed in addition to implants. You say that CPT code 22854 should be reprocessed for additional payment. The Plan denied your request. The Plan says procedure code 22854 is not supported by the medical records.  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 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (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 the insertion of intervertebral biomechanical device (22854). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not include enough documentation to describe a hole cored out of the vertebral bodies above and below the removed vertebrae to secure a biomechanical device.  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 insertion of intervertebral biomechanical device (22854) have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device (22854) provided on September 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary, and the enrollee cannot be properly treated in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 11, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from January 11, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 pre-approve inpatient psychiatric care from January 11, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 11, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond January 11, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  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 care from January 11, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 11, 2022, forward.