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

 We decided that the Plan has to pay for the initial hospital care (99222) provided on June 22, 2021.  You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because the providers at issue have different specialties. The Plan denied your request. The Plan says that both visits were for the same aspect of care.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.   We find that CPT code 99222 is supported in the record. Specifically, the record indicates that the providers at issue have different specialties and are therefore eligible for payment. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have been met. Therefore, we decided that the Plan has to pay for the initial hospital care (99222) provided on June 22, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Hereditary Cardio Screen Panel 117 Genes (CPT code(s): 81403, 81401, 81404, 81405) provided to the enrollee on April 6, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this genetic testing panel described as Hereditary Cardio Screen Panel 117 Genes is not medically necessary. The Plan states the review of the medical literature indicates that genetic testing for cardiovascular risk factors has negligible benefit in the management of a member's health. The Plan states further the clinical documentation does not support the medical necessity of the individual tests ordered and how each test would directly impact the management of the member or that the provider intended to order this testing. In addition, this testing is not a Medicare covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Hereditary Cardio Screen Panel 117 Genes (CPT code(s): 81403, 81401, 81404, 81405) provided to the enrollee on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 13, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and the enrollee should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for each specialist visit. The enrollee had a specialist visit on July 13, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. The enrollee has been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on July 13, 2021
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 22, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that the facility did nothing to treat or improve your condition, so you should not have to pay a copayment. 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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the extent of services received. 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 (ER) visit you had on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management (99397) and the office visit (99214) rendered by the out-of-network (OON) provider on June 15, 2021 and June 29, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management (99397) and the office visit (99214) rendered by the out-of-network (OON) provider on June 15, 2021 and  June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on September 16, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  September 16, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pay for therapeutic exercises (97110) provided on May 17, 2021.  You asked the Plan to pay for therapeutic exercises (97110). You say that the services were medically necessary. The Plan denied your request. The Plan says that the Plan was previously billed by another provider for this service and the provider was paid.  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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided us with proof that the Plan was billed by another provider for therapeutic exercises (97110) on this same date of service and that the Plan paid the provider. Therefore, we decided that the Plan has to pay for therapeutic exercises (97110) provided on  May 17, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) provided on July 7, 2021.  You asked the Plan to pay for the office visit. You say that you would like reconsideration because you need a new treatment method and this should be covered. The Plan denied your request. The Plan says excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine.  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 is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on September 5, 2020.  You asked the Plan to pay for the eyeglasses. You say that the Plan's vision provider did not offer the eyewear you wanted, and this provider was less expensive. The Plan denied your request. The Plan says the Plan pays for vision services with participating network providers.  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. The Plan covers these services when provided from participating network providers.  We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's participating network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on September 5, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on August 17, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls 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 August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled services of a LPN for the observation and assessment of the patient's condition, each 15 minutes (CPT code G0494) provided to the enrollee from April 1, 2020, through April 8, 2020, by a Nurse Practitioner (NPC).
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says payment is not allowed for this service because the item billed incorrectly based on the information submitted. The Plan states a corrected claim can be submitted to the claims address on the back of the enrollee's identification (ID) card with a valid service for this diagnosis for claim reconsideration. The Plan states the enrollee is not responsible for payment and this claim cannot be reprocessed for payment until a corrected claim is received.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Review of the file shows that this provider is not an LPN. Therefore, this service is not covered as billed. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore,
we decided that the Plan does not have to pay for skilled services of a LPN for the observation and assessment of the patient's condition, each 15 minutes (CPT code G0494) provided to the enrollee from April 1, 2020, through April 8, 2020, by a Nurse Practitioner (NPC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out-of-network (OON) provider on June 23, 2021.  You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue.  We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out-of-network (OON) provider on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve inpatient psychiatric services. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health
treatment beyond the date in question of December 10, 2021 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors. He was being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on June 25, 2021.  You asked the Plan to waive the copayment for the MRI. You say that you have had this MRI many times before. You say you received an incorrect MRI. The Plan denied your request. The Plan says you have been charged 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 $275 copayment for diagnostic radiology services.   The record shows the MRI you received was done as a follow up for the lesion that was found. You have been asked to pay $224.44, which is less than the $275 copayment for the MRI. The MRI 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) provided on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic molded shoes (A5501) and density inserts (A5513), provided on March 3, 2021.
You asked the Plan to pay for foot orthotics. You say that these should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has exceeded the frequency limits set in the subscriber agreement.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee has exceeded the allowed frequency limit for this benefit. Therefore, we
decided that the Plan does not have to pay for diabetic molded shoes (A5501) and density inserts (A5513), provided on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for exploratory laparotomy (CPT code 49000) provided to the enrollee on June 24, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Our records indicate a National
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 49000 and 44050. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for exploratory laparotomy (CPT code 49000) provided to the enrollee on June 24, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the retroperitoneal ultrasound you had on May 6, 2021.
You asked the Plan to waive the deductible for the ultrasound. You say that this service was not paid and you had already met your deductible a long time ago. The Plan denied your request. The Plan says you had not yet met your deductible at the time of this service.
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 $750 deductible which applies to outpatient diagnostic services. The ultrasound falls within the benefit category of outpatient diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic services. The Plan has provided a detailed breakdown of your costs that show that you had not yet met your deductible at the time of this ultrasound. Therefore, we decided that the Plan does not have to waive the deductible for the retroperitoneal ultrasound you had on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the pneumococcal polysaccharide vaccine (90732), and the administration of the pneumococcal vaccine (G0009) rendered by the out-of-network (OON) provider on August 24, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the pneumococcal polysaccharide vaccine (90732), and the administration of the pneumococcal vaccine (G0009) rendered by the out-of-network (OON) provider on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic exam (71045) provided on July 22, 2021.
You asked the Plan to pay for code 71045. 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. 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 36556. 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 radiologic exam (71045) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) and chiropractic manipulative treatment to regions other than spine (98943) provided from March 1, 2021, through April 26, 2021.
You asked the Plan to pay for the medical services. You say that these services were medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says these specific services are not covered by Medicare or the Plan.
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 services at issue were not for the manual manipulation of the spine. Therefore, we
decided that the Plan does not have to pay for the office visit (99202) and chiropractic manipulative treatment to regions other than spine (98943) provided from March 1, 2021, through April 26, 2021.