Persius/hicric huggingface dataset:
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different 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 medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on July 17, 2020, through July 
23, 2020 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says a status indicator C inpatient procedure code 
38724 was billed on the outpatient claim. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The claim at issue in this appeal was included CPT code 38724. This code is listed with a status indicator of 
C on Addendum B of the OPPS/ASC final rule. This means the service has been designated as inpatient only, and cannot be billed on an outpatient claim. Therefore, we decided that the Plan does not have to pay for 
the hospital services provided on July 17, 2020, through July 23, 2020
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the formoterol fumarate, and budesonide provided on June 
18, 2021, by the out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient drugs. You say that the services should be covered. The Plan 
denied your request. The Plan says the services in this case are not an emergency. The Plan also says that there 
are in network provider available. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the outpatient drugs at issue in this appeal. The Plan did not pre-approve the 
outpatient drugs 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 formoterol fumarate, and budesonide provided 
on June 18, 2021, by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), and limited oral evaluation (D0140), 
provided on May 4, 2021. 
 
You asked the Plan to pay for the extraction and limited oral evaluation. You say that the service should be 
covered. The Plan denied your request. The Plan says the provider 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 Plans 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 
extraction (D7210), and limited oral evaluation (D0140), provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of tunneled central venous access device
services provided on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the removal of tunneled central venous access device services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
provided are not a covered benefit.
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 removal of tunneled central venous access
device services provided on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services provided on June 30, 2021.
You asked the Plan to pay for the services provided. You say that the service should be covered by your plan. The Plan denied your request. The Plan says the services you received were not for a routine eye exam.
The Plan must follow Medicare rules. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The file shows that you received an eye exam for dry eyes. This is not considered a routine exam. The refraction services provided are only covered when included in a routine exam. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction services provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Onetouch Ultra2 provided on August 4, 2021.
You asked the Plan to pay for the Onetouch Ultra2. You say that the item should be covered. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Onetouch Ultra2 have not been met. Therefore, we decided that the Plan does not have to pay for the Onetouch Ultra2 provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 15, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 15, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an outpatient hospital facility on June 10, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you believe this procedure was strictly a screening, so you don't believe there should be a copayment. The Plan denied your request. The Plan says this procedure was performed because you had a positive Cologuard test, so it was a diagnostic procedure. The Plan says that this copayment was charged 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 $250 copayment for outpatient surgery and services at an outpatient hospital facility. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Records show that this diagnostic colonoscopy was performed because you had a positive Cologuard test. Because of this, it was ordered and performed as a diagnostic procedure, not a screening procedure. Diagnostic colonoscopies are considered surgical procedures, so the diagnostic colonoscopy falls within the outpatient surgery and services at an outpatient hospital facility 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 diagnostic colonoscopy you had at an outpatient hospital facility on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 27,
2021.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you attached the letter from the
dentist explaining the work you needed and the bill for the examination performed. You say that you cannot
afford to pay this bill. The Plan denied your request. The Plan says the service is not a covered benefit.
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
limited oral evaluation (D0140) provided on May 27, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for computed tomography (CT) guidance for placement of radiation therapy fields (77014) provided on March 17, 2021.
You asked the Plan to pay for the CT guidance for placement of radiation therapy fields. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that it is not appropriate to bill CPT code 77014 within 30 days of CPT code 77301.
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 77014 is supported in the record. Specifically, CPT code 77014 does not have a global surgery period and there are no edits that exist between CPT code 77014 and 77301 when billed on separate dates of service. There is no Medicare guidance indicating that these codes cannot be billed within 30 days of one another. Based on this information, we decided that Medicare rules for coverage of the CT guidance for placement of radiation therapy fields have been met. Therefore, we decided that the Plan has to pay for computed tomography (CT) guidance for placement of radiation therapy fields (77014) provided on March 17, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99347) and therapy services (97116, 97110) provided from July 30, 2020, to August 15, 2020.
You asked the Plan to pay for a home visit and therapy services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. The rules also say that coverage of services
and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel. We looked at the file and Medicare rules. The records do not show that the physician was present in the enrollee's home providing direct supervision. Based on this information, we decided that Medicare rules for coverage of a home visit and therapy services have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (99347) and therapy services (97116, 97110) provided from July 30, 2020, to August 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior resin-based composite (D2331), posterior resin-based composite (D2392), and two crowns (D2740 x2) provided on January 13, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the resin-based composites and crowns. You say that you asked your dentist if he ever opted in or out of Medicare and were told that he never opted out. 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 the treating provider opted out of Medicare effective February 8, 2019, to February 8, 2023.
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 anterior resin-based composite (D2331), posterior resin-based composite (D2392), and two crowns (D2740 x2) provided on January 13, 2021 by a Medicare opt out provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on January 13,
2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based
on the records submitted, The Plan denied your request. The Plan says this claim has not been billed as directed
by the Centers of Medicare and Medicaid Services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 90834 is not supported in the record. Specifically, Medicare guidance says that modifier
95 is required for telehealth services rendered during the public health emergency. This claim has not been
billed with the appropriate modifier. Based on this information, we decided that Medicare rules for coverage of
the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the
psychotherapy services (90834) provided on January 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Neuromodulation Therapy.

You asked the Plan to pre-approve Percutaneous Neuromodulation Therapy. 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 follows Medicare rules. Medicare rules say that PENS is generally reserved for patients who fail to get pain relief from TENS. 

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 Percutaneous Neuromodulation Therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no robust evidence that this device is effective in low back pain or lumbar radiculopathy. It's uses here is experimental/investigational. It 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 Percutaneous Neuromodulation Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Neuromodulation Therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by an out-of-network
provider on March 11, 2021.
You asked the Plan to pay for the physical therapy services. You say that as a participating provider with
Medicare the patient is permitted to receive physical therapy services in accordance with Medicare guidelines.
You say that the services were medically necessary, and the services should be approved for payment. The Plan
denied your request. The Plan says prior authorization for out-of-network services was not obtained.
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
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 therapy services provided by an out-ofnetwork
provider on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an
outpatient hospital facility on October 13, 2020.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you already paid
your part, so you do not feel as though you owe anything for this service. You say that this was not an
outpatient hospital procedure. The Plan denied your request. The Plan says you were charged this copayment
correctly. The Plan says that because the allowed amount for this procedure ($253.87) is less than your
copayment obligation, you are responsible for the full allowed 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 $295
copayment for surgery services at an outpatient hospital facility.
You have been asked to pay a $295 copayment for the arthrocentesis procedure. The facility where you had this
procedure is considered an outpatient hospital facility, so the arthrocentesis procedure falls within the surgery
services at an outpatient hospital facility 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 arthrocentesis procedure you had at an outpatient hospital facility on October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (onabotulinumtoxinA) for gastroparesis.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says based on the clinical guidelines, Botox is not recommended for gastroparesis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. Gastroparesis is not listed as either an FDA-approved or approved off-label indication for this request. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (onabotulinumtoxinA) for gastroparesis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 74177, J7050, and Q9967
provided on March 15, 2021.
You asked the Plan to pay for the medical services. You say that the medical records support the codes as
billed. The Plan denied your request. The Plan says the documentation does not corroborate the services.
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 74177 is computed tomography, abdomen and pelvis;
with contrast material(s). The CPT Code Manual definition of code J050 is infusion, normal saline solution,
250 cc. The CPT Code Manual definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml
iodine concentration, per ml.
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 medical services. Our reviewer says that the billed codes
are not supported in the medical records. Our reviewer found the documentation submitted does not include a
computed tomography (CT) of abdomen and pelvis with contrast material was performed on March 15, 2021.
Documentation states "She does have an elevated alkaline phosphatase and I think it would be worthwhile to
check a CT of the abdomen to rule out small bowel lesion, pancreatic or liver disease that may be contributing
to her symptoms. Her exam today is completely benign." In this case 4177, Q9967 and J7050 cannot be
confirmed as performed, as there is no documentation of the procedure.
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 medical services have not been met. Therefore, we decided that the Plan
does not have to pay for the medical services coded as 74177, J7050, and Q9967 provided on March 15, 2021.