Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 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 procedure code 70450 is 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 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 7, 2021
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for the ankle dislocation treatment. We decided that the Plan does not have to pay for the simple repair and emergency department visit.
You asked the Plan to pay for the simple repair, ankle dislocation treatment and emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan says that the documentation submitted does not support the service billed.
We decided that the Plan has to pay for the closed treatment of an ankle dislocation.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 ankle dislocation treatment. Our physician reviewer found CPT code 27840 is supported in the medical record. The documentation clearly documents closed treatment of ankle fracture and should be covered separately from the evaluation and management services provided. 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 ankle dislocation treatment have been met. Therefore, we decided that the Plan has to pay for closed treatment of an ankle dislocation.
We also decided that the Plan does not have to pay for the simple repair and emergency department visit.
The Plan follows Medicare rules. Medicare rules say providers must report services correctly. 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 simple repair and emergency department visit. Our reviewer says that the documentation does not support the level of service indicated by CPT code 99285. The documentation does not support that 3 of 3 key components have been met or exceeded to report this code. CPT code 12002 has a bundled relationship with CPT code 27840 and was not billed with the required modifier to indicate that this was a separate and distinct procedure.
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 simple repair and emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the simple repair and emergency department visit.
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 an office visit provided on January 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that the previous authorization expired. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization 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 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 an office visit provided on January 12, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (72170) provided to the enrollee on May 20, 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 an appropriate modifier was not 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 the
services has a bundled relationship with code 72170 and cannot be paid as billed without a modifier. A modifier was not billed in this case. 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 radiology services (72170) provided to the enrollee on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1820) provided on February 24, 2021.

You asked the Plan to pay for a right knee orthosis. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1820) provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 6, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not know the frequency limitation for the comprehensive oral evaluation until after the service had been rendered. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.
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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on November 21, 2019 and your comprehensive oral evaluation
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray rendered on May 24, 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 code 74018 is 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 74018 (abdomen x-ray, one view) and 74022 (complete
abdomen x-ray). Code 74018 is a column II code with a modifier indicator of 1 when billed with column I code
74022. Code 74018 was not billed with an appropriate modifier to allow for separate payment. Therefore, we
decided that the Plan does not have to pay for the abdomen x-ray rendered on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing panel coded as 81286, 81408 and 81479 provided December 22, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing panel. You say that you are attaching medical records to process the claim for payment. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing panels.

The Plan must follow Medicare rules. Medicare rules say that cardiovascular risk assessment testing panels is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment testing panel have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing panel coded as 81286, 81408 and 81479 provided December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits and psychotherapy provided from February 11, 2021, to March 25, 2021.

You asked the Plan to pay for office visits (99212) and psychotherapy (90836). You say that you would appreciate the Plan to continue to pay your claims. The Plan denied your request. The Plan says the provider has opted out of Medicare and is not covered under your plan.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visits and psychotherapy provided from February 11, 2021, to March 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on November 4, 2020.

You asked the Plan to waive the copayment for emergency services (99284, 83690, 80053, 85025, 81003). You
say that you left the ER without being treated so you should not have to pay. The Plan denied your request. The
Plan says you were charged this coinsurance 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 $90
copayment for Emergency Care.

You have been asked to pay a $90 copayment for emergency services. Emergency services fall within the
Emergency 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 emergency care
provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and endodontic
therapy (D3330) provided on June 21, 2021, by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray and endodontic therapy. You say that a
concierge was brought into your call and recommended this provider to you. The Plan denied your request. The
Plan says these services were rendered by an OON provider. The Plan also says that you were given the names
and addresses of in-network endodontists, and this treating provider was not one of them.
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 OON. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray (D0220) and endodontic therapy (D3330) provided on June 21, 2021, by an OON
provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services and items provided to the enrollee on February 25, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services and items provided to the enrollee on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry stain provided on April 14, 2021, billed with code 88342.
You asked the Plan to pay for the immunohistochemistry stain as billed. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says 88342 was billed along with 88360 and was not reported with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that Column 2 codes in a NCCI edit pair are only payable when the modifier indicator is 1, and a clinically appropriate modifier is used.
Code 88342 is a Column 2 code in relation to 88360, with a modifier indicator of 1. However, this line item of 88342 was not billed with a clinically appropriate modifier. As such, separate payment cannot be made. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry stain provided on April 14, 2021, billed with code 88342.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), retainer crowns (D6752 x 2), and pontic (D6242) provided on April 14, 2021.

You asked the Plan to pay for the dental services. You say that you were advised that you did not require referral from your primary care physician to seek services from a specialist. You also say that these services should be covered. The Plan denied your request. The Plan says extraction is not listed as a covered service. The Plan says that retainer crowns are not listed as covered services. The Plan says that pontic is not listed as a covered service either. The Plan also says if the dental care you need is expected to exceed $300, or if you simply want to know the specific coverage up front, we suggest you or your dentist send a dental treatment plan for us to review ahead of time.

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 extraction, retainer crowns, and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), retainer crowns (D6752 x 2), and pontic (D6242) provided on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from March 20, 2021, through March 21, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you were given medications as directed by the doctors. The Plan denied your request. The Plan says these are not Part B covered drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from March 20, 2021, through March 21, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services (36415, 80053, 80061, 84443, 85025) provided on May 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the lab testing. You say that your records show that the enrollee participates in a different plan which does not require only in-network care. The Plan denied your request. The Plan says generally out-of-network services are not covered by the enrollee's plan. The services at issue were not urgent or emergent, nor were they pre-approved. The Plan called the enrollee's primary care provider and verified that they did not refer the enrollee for these services. Payment will not be made.
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.
We verified enrollment records with Centers for Medicare and Medicaid Services (CMS). Records confirm that the enrollee switched to a new plan with the same company effective March 1, 2021. The enrollee's plan on the date in question requires the enrollee to get services from in-network providers, except in limited circumstances. 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, and documentation indicates that the enrollee's primary-care provider did not refer these services. 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 lab testing services (36415, 80053, 80061, 84443, 85025) provided on May 18, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient care from September 24, 2021, forward.
You asked the Plan to pre-approve acute inpatient care from September 24, 2021, forward. You say that acute inpatient care from September 24, 2021, forward is medically necessary. The Plan denied your request. The Plan says that acute inpatient care from September 24, 2021, forward is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 acute inpatient care from September 24, 2021, forward. Our reviewer says that the continued stay is medically necessary and reasonable, as defined by Medicare rules. Our physician reviewer found the provided records indicate that the enrollee had improved by September 23, 2021 and required placement in a subacute rehabilitation facility. No bed was available, and no safe discharge was available. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient care from September 24, 2021, forward have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient care from September 24, 2021, forward.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and hypertension. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided on February 18, 2021.
You asked the Plan to pay for a total electric hospital bed. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided on February 18, 2021.