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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show that the enrollee requires daily skilled services that can only be provided on an inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99100, 99140) provided on March 25, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Procedure codes 99100 and 99140 are assigned a status indicator of "B" under the Physician Fee Schedule, which means that these are bundled services. Payment for these services is bundled into payment for other services. No separate payment can be made for these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99100, 99140) provided on March 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hearing testing to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve hearing tests. You say that the enrollee has a bad experience with the Plan's in-network provider and refuses to attend that location. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve hearing testing to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on
June 9, 2021, through June 11, 2021.
You asked the Plan to waive the copayment for inpatient hospital services. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share 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 $395
copay per days one through five for inpatient hospital care.
You have been asked to pay a $395 copay per days one through five for inpatient hospital services. Inpatient
hospital services fall 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 the inpatient hospital services provided on June 9, 2021, through June 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the chest (71045), provided on April 21, 2021.
You asked the Plan to pay for the chest x-ray. You say that the service should be covered. The Plan denied your request. The Plan says the member was enrolled in hospice during the time of service.
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 the radiologic examination (x-ray) of the chest (71045), provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic office visit with a vision specialist (99204, 92134) rendered on July 28, 2021.
You asked the Plan to waive the copayment for a diagnostic office visit with a vision specialist. You say that you do not feel you should have to pay for two specialists fees when you were sent to multiple providers for the same problem. You also say that you clearly had a retinal problem to begin with and the providers knew that there was not a retinal specialist at the first office. The Plan denied your request. The Plan says you were 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 $45 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.
You have been asked to pay a $45 copayment for a diagnostic office visit with a vision specialist. a diagnostic office visit with a vision specialist falls within the Vision 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 a diagnostic office visit with a vision specialist (99204, 92134) rendered on July 28, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2311, E2377, E2313).
You asked the Plan to pre-approve the expandable controller for a power wheelchair. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 the expandable controller for a power wheelchair. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the provided records did not support the need for a joystick to control the chair as the other more standard methods of controlling the device should be reasonable for this patient. 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 expandable controller for a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2311, E2377, E2313).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on June 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the screening digital breast tomosynthesis (77062) provided February 15, 2021.  You asked the Plan to pay for the diagnostic service. You say that effective January 1, 2015 HCPCS code 77062 must be billed in conjunction with the screening mammography. Therefore, use of a modifier is not needed and it should be paid in addition to the other charges. The Plan denied your request. The Plan says this is an invalid procedure code for this service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 77062 is screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).  We find that CPT code 77062 is not supported in the medical record. Specifically, procedure code 77062 has a status code of I which is not valid for Medicare purposes. Medicare guidance says status code "I" = not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the screening digital breast tomosynthesis (77062) provided February 15, 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 July 2, 2021.
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 must 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 July 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on June 11, 2021.
You asked the Plan to pay for the radiology services. You say that the services should be covered. The Plan
denied your request. The Plan says the member was enrolled in hospice during that time of service.
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 the radiology services provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided beyond 30 visits from March 24, 2021 to July 2, 2021.
You asked the Plan to pay for these services. You say that these visits should be covered by the Plan. The Plan denied your request. The Plan says 30 visits were covered by the Plan. Any services beyond that are not covered per the Plan contract.
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 the chiropractic benefit is limited to 30 visits per year. The Plan provided records to show the Plan provided coverage for 30 visits. Once this benefit is exhausted it cannot be extended. Therefore, we decided that the Plan does not have to pay for chiropractic services provided beyond 30 visits from March 24, 2021 to July 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (93976) provided on July 30, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93976 is a column II code to column I code 76856. 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 services (93976) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code(s): 80307 and G0483) provided
to the enrollee on May 12, 2021.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
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 drug testing have not been met. CPT code(s): G0483 and 80307
are not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient
when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in
a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the
specimen was collected on May 12, 2021, and received by the lab on May 14, 2021; therefore, the billed codes
cannot be verified. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code(s):
80307 and G0483) provided to the enrollee on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics (CPT code A9279) provided to the enrollee on May 20, 2021.
You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. The Plan says claims for A9279 are denied as statutorily non-covered. 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 item have not been met. Your request for additional payment for A9279 is not a covered benefit because payment for this service is incorporated into the payment for the base item, in this case, the enrollee's continuous positive airway pressure (CPAP) device. Therefore, we decided that the Plan does not have to pay for monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics (CPT code A9279) provided to the enrollee on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care to be provided with a lumbar fusion.
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says they have agreed to cover the lumbar fusion surgery as an outpatient procedure; however, the subsequent inpatient admission and care are not medically necessary for this procedure.
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 inpatient payment are met in this case. Our physician reviewer found the enrollee is medically stable at this time and has been approved for decompression posterior lumbar interbody fusion. The procedure does not require inpatient level of care for services. This review has determined that the record does not show that at the time of inpatient admission, the admitting physician would reasonably expect the enrollee's necessary hospital care (including earlier emergency department 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 pre-approve the acute inpatient hospital care to be provided with a lumbar fusion
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospice room and board (Q5004) provided on April 1, 2021.  You asked the Plan to pay for the hospice room and board. You say that you would like reconsideration because you are just charging room and board to be able to pay the Skilled Nursing Facility. The Plan denied your request. The Plan says this claim was not billed with an appropriate revenue code for hospice services.  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 the hospice room and board (Q5004) provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a limited oral evaluation (D0140) provided on March 2, 2021.
You asked the Plan to reimburse you for a limited oral evaluation. You say that you received reimbursement for dental expenses. You also say one of the claims is not included in that reimbursement. You are requesting reconsideration of that claim. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed for this type of 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.
We looked at the file and Medicare rules. The records show that you were reimbursed $1,764 for dental services received from February 25, 2021, to April 5, 2021 and $108 for dental services received on July 12, 2021. The records also show that you were reimbursed $128 for dental services received on March 2, 2021. The remaining balance for the date of service on March 2, 2021 is not covered as you have reached your $2,000 total maximum allowed benefit for dental services. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to reimburse you for a limited oral evaluation (D0140) provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided from January 24, 2020, to January 31, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not supported.  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 diagnosis code J18.9. 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 services. Our reviewer says that the billed diagnosis code is not supported. Our physician reviewer found that although pneumonia was mentioned on discharge summary, it was not documented as a discharge diagnosis. The use of diagnosis code J18.9 is not supported by the records provided.   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 services provided from January 24, 2020, to January 31, 2020.