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

 We decided that the Plan does not have to pay for the incomplete root canal (D3332), and extraction (D7210) provided on June 23, 2021.  You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says there is a 50% coinsurance for extractions. The Plan says that dental service received out of network may cost more. The Plan also says that the incomplete root canal is not 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 and extractions are listed as covered, there is a 50% coinsurance that applies. The record shows that the Plan paid 50% ($46.28) of the allowed amount ($92.50). Out of network providers may bill you for any amount greater than what the plan pays. Additionally, incomplete root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incomplete root canal (D3332), and extraction (D7210) provided on June 23, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency department services provided to the enrollee on July 7, 2021.  You asked the Plan to pay for the services. You say that per the medical records submitted, the claim was billed with an appropriate diagnosis code which is payable. The Plan denied your request. The Plan says the claim was not billed correctly.  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 99284 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found based on the records provided and the 2021 ICD-10 CM coding and billing guidelines, the use of ICD10 code T50.995A as the primary diagnosis was not appropriate and thus coverage for CPT 99284 is denied.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services provided to the enrollee on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit services provided on August 31, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit 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 received were neither emergent nor urgent and prior authorization was not obtained to seek 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 office visit services provided on  August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiologic examination (72170) provided on August 8, 2021.  You asked the Plan to pay for code 72170. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two separate x-rays were provided on August 8, 2021. The file shows that the Plan paid for one set of x-rays (72170-26) provided on August 8, 2021. Therefore, we decided that the Plan does not have to pay for the radiologic examination (72170) provided on August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-covered chiropractic service (99212) provided on July 22, 2021.  You asked the Plan to pay for code 99212. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 99212 is not covered when billed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue, code 99212 is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic service (99212) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-Medicare covered chiropractic service (99211) provided on June 17, 2021.  You asked the Plan to pay for the non-Medicare covered chiropractic service (99211). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the correct copayment has applied.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan provides additional services provided by a chiropractor beyond Medicare coverage.       The Plan contract says that additional services provided by a chiropractor are covered only when in conjunction with a covered manipulation. The records show that the service at issue is not manual manipulation of the spine. The claim submitted only shows the provider billed code 99211 and no manipulation of the spine was performed during this visit. Therefore, we decided that the Plan does not have to pay for the non-Medicare covered chiropractic service (99211) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist visit provided on July 20, 2021.  You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  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 each Medicare-covered visit with a specialist.   We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on July 20, 2021. You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 specialist visit provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you a $150 allowance for eyeglasses provided on  August 4, 2021.  You asked the Plan to reimburse you a $150 allowance for eyeglasses. The Plan denied your request. The Plan says that the Plan received a reimbursement request from the provider for the eyeglasses and payment was issued to the provider.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plan received a reimbursement request from the provider for the eyeglasses and payment was issued to the provider. Therefore, we decided that the Plan does not have to reimburse you a $150 allowance for eyeglasses provided on August 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided October 8, 2020.  You asked the Plan to waive the copayment for the ambulances transport. You say that you don't feel you should be responsible for the copayment since you were transported due to faulty medical equipment. The Plan denied your request. The Plan says the copayment was applied 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 each one-way Medicare covered ground ambulance trip.  You have been asked to pay $227.68 for the ambulances transport. This transport falls within the Ambulance services benefit category. This means that you have been asked to pay less than or equal to 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 ambulance service, basic life support, non-emergency transport (A0428) provided October 8, 2020.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for imaging transportation services (procedure code R0070) provided to the enrollee on July 28, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the claim does not meet the coding standards.  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 procedure code R0070 is "Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen."  We 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 services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found documentation was not found to support Medicare rule to report HCPCS R0070 or HCPCS R0075 with HCPCS Q0092 set up portable x-ray equipment. Medicare does not allow a transportation charge when the x-ray equipment is stored in a nursing home for use as needed; however, HCPCS Q0092 for set-up payment is payable in such situations. Since the provider reported x-ray equipment transportation, then the equipment was not kept at the facility. If the equipment is stored at a facility, then a setup fee would be appropriate to charge.   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 services have been met. Therefore, we decided that the Plan has to pay for imaging transportation services (procedure code R0070) provided to the enrollee on July 28, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the facial X-ray (70150) provided on December 1, 2020.  You asked the Plan to waive the copayment for the facial X-ray. You say that you would like this copayment waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.  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 $15 copayment for Medicare-covered X-rays performed in any location other than a primary care physician or Specialist's office.   You have been asked to pay a $15 copayment for the facial X-ray. This service falls within the Medicare-covered X-rays 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 facial X-ray (70150) provided on December 1, 2020.
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 a participating provider on July 8, 2021, to July 13, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are on a fixed income and cannot afford to pay. 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 $300 copayment. You will not pay more than $900 for inpatient hospital for inpatient hospital care.   You have been asked to pay a $300 copayment for an inpatient hospital stay. The correct copayment has been applied to the inpatient hospital services that were provided. An inpatient hospital stay falls within the inpatient hospital care 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 a participating provider on July 8, 2021, to July 13, 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 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 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 IRF admission is not medically necessary based on lack of medical complexity and with no rehabilitation nursing needs and high functional level. Documentation does not support the necessity for admission to IRF.  
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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. 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 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 IRF admission is not medically necessary based on lack of medical complexity and with no rehabilitation nursing needs and high functional level.  Documentation does not support the necessity for admission to IRF.  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 pay for the inpatient hospital care provided from January 24, 2021, through January 29, 2021, as billed.  
You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the inpatient care as it was originally billed. The Plan denied your request. The Plan says the secondary diagnosis code billed 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    
In this case, you billed the inpatient services provided with secondary diagnosis code, I50.33, defined as acute on chronic diastolic (congestive) heart failure. 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 inpatient hospital care as billed. Our reviewer says that the documentation does not support the secondary diagnosis code of I50.33, defined as acute on chronic diastolic (congestive) heart failure. 
Our physician reviewer found that the documentation supported an admission for further evaluation and treatment of a gastrointestinal bleed in a patient with a known history to include heart failure. The documentation included a diagnosis of congestive heart failure (CHF) and the Cardiology consultant documentation noted heart failure with preserved ejection fraction (HFpEF) with volume overload. Review of the documentation received was incomplete to reflect the acuity of the heart failure diagnosis during this encounter to substantiate code assignment of I50.33. The review has determined that the documentation did not support the billed secondary diagnosis I50.33.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from January 24, 2021, through January 29, 2021, as billed.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray of the chest (71045) provided on September 16, 2021.  You asked the Plan to pay for the X-ray of the chest. You say that this claim should be reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare rules.  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 71045 is a column II code to column I code 71046. 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 X-ray of the chest (71045) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on May 23, 2021.  You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 23. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on May 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the bone replacement graft for ridge preservation (D7953) provided on August 14, 2021.  You asked the Plan to reimburse you for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says the bone replacement graft for ridge preservation 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 bone replacement graft for ridge preservation is not among those covered under this benefit. Additionally, the record shows that you signed a treatment plan acknowledging $0 plan payment and accepting responsibility for the cost of the service. Therefore, we decided that the Plan does not have to reimburse you for the bone replacement graft for ridge preservation (D7953) provided on August 14, 2021.