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

We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement coded as 76942 provided on March 24, 2021.
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the claim was not submitted 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 76942 has a bundled relationship with code 76536 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 ultrasonic guidance for needle placement coded as 76942 provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a removal of impacted tooth (D7240) provided on May 25,
2021.
You asked the Plan to pay for a removal of impacted tooth. You say that you did not know the service at issue
is not covered. The Plan denied your request. The Plan says rules for payment for dental services have not been
met.
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 service is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a removal of
impacted tooth (D7240) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on November 11, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on November 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.

You asked the Plan to pre-approve 6 additional physical therapy visits. You say that 12 visits were approved, and you are requesting 6 additional visits. The Plan denied your request. The Plan says additional visits are 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 6 additional physical therapy visits. 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 patient has had prior therapy and is compliant with the home exercise program. Our reviewer says that the unique skills of a professional therapist are required to safely and effectively provide treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on January 6, 2021, by an OON
provider.
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 rest home visit provided on January 6, 2021,
by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient
hospital facility on March 23, 2021.
You asked the Plan to waive the copayment for the lab services. You say that there was no transparency about
this copayment, so it should be waived. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that since the allowed amount for these lab services ($25.20) 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 $40
copayment for lab services at an outpatient hospital setting.
You have been asked to pay a $40 copayment for the lab services. 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 lab services you received at an outpatient hospital facility on March 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 20, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease (99072) provided from January 18, 2021, through March 6, 2021.
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that precautions were taken by the provider of the service prior to treating the patient. The Plan denied your request. The Plan says CMS considers these services bundled with the services provided to the enrollee on the same dates of service and is therefore not eligible for separate reimbursement.
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 additional supplies, materials, and clinical staff time has a bundled relationship with code 99072 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 additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease (99072) provided from January 18, 2021, through March 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the patient is at a maintenance level to prevent her from getting worse and needing more assistance at home. You say that Medicare allows for this level of maintenance care and you are appealing the denial. The Plan denied your request. The Plan says additional visits are 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 physical therapy visits. 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 patient has had extensive prior therapy for this condition and has been instructed in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 

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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you had no control over which hospital you went to. You also say that you feel you should not be stuck with these charges. The Plan denied your request. The Plan says the inpatient hospital admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this
case. Our physician reviewer found the provided documentation shows that you were initially admitted to observation. The reviewer found that you were stable upon admission. Recent documentation did not suggest a special circumstance or clinical presentation that would suggest they required hospital services that would cross 2 midnights for this lower risk surgery. Therefore, the reviewer found that an inpatient admission would not be medically reasonable or necessary. 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 hospital care have not been met. Specifically, the file does not indicate that that the required services would cross 2 midnights. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic retainer crown (D6740) provided on March 31, 2021.
You asked the Plan to pay for the retainer crown. You say that you were told prior to services that you would only owe $204 for the dental care and are frustrated that you are being billed an additional amount after the fact. You cannot afford this extra cost. The Plan denied your request. The Plan says you have met your annual $4,500 allowance for supplemental dental care. You are responsible for any charges that exceed this allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover up to $4,500 every year for supplemental dental services. You are responsible for any amount above the dental coverage limit.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plan's $4,500 annual dental coverage limit are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic retainer crown (D6740) provided on March 31, 2021.
Your complaint about potential misinformation regarding your coverage from a dental plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis you had on June 1, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you were never told that the copayment was going to be this high. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this CT scan ($129.55) 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 $300 copayment for CT scans. You have been asked to pay a $300 copayment for the CT scan. 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 computed tomography (CT) scan of the abdomen and pelvis you had on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 28, 2021, to April 29, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care following the hip arthroplasty procedure was medically necessary because of the enrollee's multiple co-morbidities which posed a greater risk of postoperative complications. The Plan denied your request. The Plan says the inpatient care following the total hip arthroplasty (27130) was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was medically stable and was provided medical clearance to undergo this elective procedure. The provided procedure, listed under procedure code 27130, is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The arthroscopy procedure was approved as an ambulatory outpatient procedure. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 28, 2021, to April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with knee surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is having difficulty walking and it is affecting their daily living, and these services are medically necessary. The Plan denied your request. The Plan says they have agreed to cover the total knee arthroplasty (27447), but only as an ambulatory procedure. It is not medically necessary for this procedure to be provided as an inpatient procedure, and therefore the requested inpatient care is denied.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the provided documentation, there is no suggestion that this enrollee would require hospital services that would likely cross two midnights for this lower risk 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with knee surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a vision program provided on May 7, 2021.
You asked the Plan to reimburse you for a vision program. You say that you would like to be reimbursed for your eyewear as you were unaware of a plan change. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you receive $100 allowance towards the purchase of eye wear every two years. We looked at the file and the Plan's rules. The records show the miscellaneous vision program is not covered by the Plan. The EOC shows that the $100 allowance only applies to frames and lenses. Based on this information, we decided that the Plan's rules for coverage of vision program have not been met. Therefore, we decided that the Plan does not have to reimburse you for a vision program provided on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs admission into a LTACH because he is on a ventilator. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing coded 81479 provided on January 14, 2021.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation does not include an order from the enrollee's treating physician for these genetic testing services. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing coded 81479 provided on January 14, 2021.