Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extension of coverage of an intensive outpatient program (IOP) level of care.
You asked the Plan to pre-approve the extension. You say that there is concern for regression. The Plan denied your request. The Plan says there is no significant dysfunction, medication side effects, or other significant changes that would warrant readmission.
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 extension. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are requesting pre-service authorization for readmission to an intensive outpatient program for an additional 10 sessions from September 13, 2021 forward. The enrollee suffers from obsessive-compulsive disorder and social anxiety. Based on a review of the records provided, it is noted that the enrollee was compliant with treatment utilizing medication and involved actively in the treatment program. She has made significant progress by cutting her cleaning time in half. The enrollee has no suicidal or homicidal thoughts and is able to care for basic needs including activities of daily living. Based on the information,
provided, the enrollee no longer meets criteria for treatment at the intensive outpatient treatment level of care, and could be treated in a lesser restrictive environment. 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 extension have not been met. Therefore, we decided that the Plan does not have to pre-approve an extension of coverage of an intensive outpatient program (IOP) level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had at an oncologist's office
on June 14, 2021.
You asked the Plan to waive the copayment for the oncology visit. You say that you only saw the nurse
practitioner, not the doctor, on this date of service. The Plan denied your request. The Plan says you were
charged this copayment 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 for physician/practitioner services in a specialist's office.
The records show that you had an office visit with a nurse practitioner at the oncology office. You have been
asked to pay a $40 copayment for the oncology visit. The specialist copayment applies to both physician and
practitioner services you receive in a specialist's office. 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 visit you had at an oncologist's office on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation therapy (97014) provided on May 7, 2021.
You asked the Plan to pay for electrical stimulation therapy. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with a valid code.
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 97014 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation therapy (97014) provided on May 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on June 7, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you do not know the reason for
this bill. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan
says that because the allowed amount for this service ($83.69) 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 $110
copayment for radiological diagnostic services, including ultrasounds.
You have been asked to pay a $110 copayment for the ultrasound. The ultrasound falls within the radiological
diagnostic 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 copayment for the ultrasound you
had on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal
(45385) provided on May 18, 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 $95 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. Additionally, a colonoscopy or sigmoidoscopy conducted for polyp removal or biopsy is a surgical procedure subject to outpatient surgery cost sharing. You have been asked to pay a $95 copayment for the Medicare-covered outpatient surgery 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 copayment for the colonoscopy with lesion removal (45385) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure (D5899) provided on February 26, 2021.
You asked the Plan to pay for the dental service. You say that you do not know this doctor. You also say that you never had anything done. The Plan denied your request. The Plan says unspecified removal prosthodontic procedure is not listed as a covered service. The Plan also says that you were advised prior to receiving the customized denture that it would not be covered.
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 unspecified removal prosthodontic procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure (D5899) provided on February 26, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes
place.
We looked at the file and Medicare rules. In this case, the services were billed with POS code 22. However, the
enrollee was an inpatient when the services were provider. Therefore, the outpatient POS code is inappropriate
to use 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 provided on June 13,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 27, 2020.
You asked the Plan to pay for laboratory services. You say that this was ordered by the physician. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. These services were billed with an office place of service code, but the records show that the sample was taken in a skilled nursing facility. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 1, 2020.
You asked the Plan to pay for lab tests. You say that the diagnosis and procedure meet the standards of medical necessity. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure codes 99100 and 00910) provided to the enrollee on April 20, 2021.
You asked the Plan to pay for the services. You say that the processing of this claim should be reviewed, as it is not inclusive to the primary procedure. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is: CPT 99100: Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) CPT 00910: Anesthesia for transurethral procedures (including urethrocystoscopy); not otherwise specified We find that CPT code is not supported in the medical record. Specifically, despite multiple attempts, the provider has not provided any clinical records to review the veracity of the codes billed. 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 anesthesia services (procedure codes 99100 and 00910) provided to the enrollee on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT.
You asked the Plan to pre-approve additional PT. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy of fifteen (15) outpatient visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) any joint of lower extremity (73721) provided April 27, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you are appealing this copayment because you cannot afford it. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $0 or $95 copayment for Medicare covered diagnostic radiology services (not including x-rays).
You have been asked to pay $95 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for the magnetic resonance imaging (MRI) any joint of lower extremity (73721) provided April 27, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on May 17, 2021.
You asked the Plan to pay for the dental service. You say that you feel that this service should be covered. The Plan denied your request. The Plan says partial lower denture is not listed as a covered service.
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 partial lower denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial lower denture (D5214) provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 17, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on June 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 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 services (70450) provided on June 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services rendered on March 9, 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 procedure codes 95822 and 95812 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 95822 (EEG recording in coma or sleep only), 95812 (EEG extended monitoring, 41-60 minutes), and 95813 (EEG extended monitoring, 61-119 minutes). Codes
95822 and 95812 are column II codes with a modifier indicator of 1 when billed with column I code 95813. Codes 95822 and 95812 were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) services rendered on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device is considered experimental, investigational, and unproven for all indications.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of an evaluation by either an orthopedic or neurosurgical
spine surgeon.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device 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 the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 the enrollee needs 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 the enrollee's 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 for the enrollee.