Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital admission.
You asked the Plan to pay for an inpatient hospital admission. You say that the records provided support the need for an inpatient level of care. The Plan denied your request. The Plan says an inpatient hospital admission is 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 an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this case.
Our physician reviewer found the enrollee was admitted to observation care in the hospital for atrial flutter and congestive heart failure. The enrollee was given diuretics and diltiazem intravenously and improved with treatment. The enrollee troponins were negative. There was no hypoxia present. He was transitioned to oral medications 2 days later. He was admitted to inpatient care. However, due to the low complexity of the case, it was not expected that the enrollee would require at least 2 midnights of hospital 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 an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission.
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 14, 2021.
You asked the Plan to pay for the limited evaluation. You say that this service was necessary and should be covered. The Plan denied your request. The Plan says this type of evaluation is not covered by your dental 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. The Plan can cover up to two oral exams every calendar year; either D0120, D0150 or D0180. 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 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on February 2, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray
(D0330), topical application of fluoride varnish (D1206), the unspecified preventive service (D1999),
prophylaxis (D1110), and bitewing x-rays (D0274) provided on September 9, 2020.
You asked the Plan to pay for the dental services. You say that you upgraded your plan in 2020 because you
planned to have extensive dental work performed. You say that you changed your mind and asked for the more
expensive plan to be cancelled. You say that you went for a routine appointment later in the year and received a
bill for the services. You also say that you were advised by a plan representative that your coverage would be
reinstated, and the bill would be covered. The Plan denied your request. The Plan says your policy in 2020 no
longer offers the free dental coverage you had in 2019. The Plan says that only optional supplemental dental
benefits were available, which you had cancelled. The Plan says that since you cancelled your dental coverage,
you no longer had a dental plan for the remainder of 2020.
Medicare generally does not cover dental services. The Plan follows the same rule.
Though the Plan offers a dental benefit in excess of Medicare coverage, you were not enrolled in an optional
supplemental dental plan. The services you are asking the Plan to pay for involve the care, treatment, filling,
removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These
are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), topical application of
fluoride varnish (D1206), the unspecified preventive service (D1999), prophylaxis (D1110), and bitewing x-rays
(D0274) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services rendered on April 7, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the podiatry services rendered on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided May 4, 2021, and the reline complete maxillary denture (indirect) (D5750) provided May 7, 2021.
You asked the Plan to pay for the comprehensive oral exam and reline complete upper denture. You say that you did not know at the time of the services that the provider was out-of-network. The Plan denied your request. The Plan says the out-of-network claims were processed correctly.
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 the comprehensive oral exam with a $0 enrollee responsibility when provided by a participating provider and covers 50% of the covered Plan allowance for reline complete upper denture. We looked at the file and Medicare rules. The Plan provided documentation showing that they covered the full Plan allowance amount for the comprehensive oral exam and 50% of the Plan allowance amount for the reline dentures. You were responsible for more because the services were provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided May 4, 2021, and the reline complete maxillary denture (indirect) (D5750) provided May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on April 17, 2021.
You asked the Plan to pay for the computed tomography. 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, we have confirmed that code 70450 for the computed tomography has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography coded 70450 provided on April 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0117U) provided May 12, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this service is considered investigational and is not covered.
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 pay for the lab services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found Foundation Pain Index (FPI) testing was performed. Insufficient clinical records
were provided to support that this type of testing was medically necessary in this case.
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 lab services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services (0117U) provided May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral lateral nerve branch blocks for the enrollee.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that a first or second set of confirmatory medial branch blocks were completed at the L5-S1 region. 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral lateral nerve branch blocks for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99406) provided on April 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not
payable.
The Plan must follow Medicare rules. Medicare rules say that If more than one evaluation and management
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one
physician in the same specialty in the same group, only one evaluation and management service may be
reported.
We looked at the file and Medicare rules. In this case, the requested E/M code, 99406, was provided on the
same date and by the same physician as E/M code 99239, which has been paid by the Plan. As only one E/M
code is payable to the same physician on the same date of service, code 99406 is not payable in this case. 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 the services (99406) provided on April 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
You asked the Plan to pre-approve 7 home health skilled nursing visits. 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. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 7 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation to support the need for skilled nursing services. There is no documentation that the enrollee is in need of any specific therapies for a specific condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services you received on March 23, 2021.
You asked the Plan to waive the deductible for the lab services. You say that you feel as though your deductible should be waived because you have already paid over $10,000 towards insurance this year. The Plan denied your request. The Plan says you had not yet met your annual deductible at the time you had these lab services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 annual deductible which applies to lab services. The deductible applies to lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 annual deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on March 23, 2021. The deductible only applies to certain services, so the fact that you have paid money towards other services that the deductible
does not apply to does not factor into your deductible calculation. Therefore, we decided that the Plan does not
have to waive the deductible for lab services you received on March 23, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from
May 10, 2021, to May 13, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted to
the hospital and the emergency copayment does not apply. 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 $90
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows you were in observation which is considered
an outpatient service. 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 emergency room visit
provided from May 10, 2021, to May 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued SNF stay.
You asked the Plan to pre-approve the continued SNF stay. The Plan denied your request. The Plan says you do not meet the criteria for a continued SNF stay.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continued SNF stay. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued SNF stay.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for gum lesion drainage (41800) provided on March 20, 2020.
You asked the Plan to pay for gum lesion drainage. You say that this was billed correctly. The Plan denied your request. The Plan says that this requires modifier -54.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules state that where physicians agree on the transfer of care during the global period, modifier "-54" is used for surgical care only. An exception occurs when physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The record shows that the service at issue is a minor surgery that was performed in an emergency room. Modifier -54 is not used in this circumstance. The Plan has not provided information demonstrating that the modifier is required. Therefore, we decided that the Plan has to pay for gum lesion drainage (41800) provided on March 20, 2020.
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 anesthesia services (99100) provided February 25, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services 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. 
We find that CPT code 99100 is not supported in the medical record. Specifically, per the 2021 National Physician Fee Schedule, this service has a status of "B" and is always bundled with a primary service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided February 25, 2021.