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

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July
28, 2021, to August 4, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you feel that the enrollee
was discharged too soon because they had to be readmitted at a later time. 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 $260 copayment for days 1-5 for inpatient hospital care.
The enrollee had an inpatient hospital stay from July 28, 2021, to August 4, 2021. Therefore, the enrollee is
responsible to pay a $260 copayment for days 1-5 (July 28, 2021, to August 1, 2021). The total amount the
enrollee owes is: $260 (copayment) x 5 (inpatient hospital care) = $1,300.
The enrollee has been asked to pay the total copayment amount of $1,300 for inpatient hospital care. Inpatient
hospital care falls within the inpatient hospital care 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 inpatient hospital care provided from July 28, 2021, to August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on June 16 - June 26,
2020, billed with diagnosis code G93.41.
You asked the Plan to pay for inpatient hospital services billed with diagnosis code G93.41. You say that the
diagnosis code in dispute was appropriately used and the claim should be paid as billed. The Plan denied your
request. The Plan says metabolic encephalopathy is not a valid diagnosis for the inpatient hospital services
received.
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, G93.41, defined as metabolic
encephalopathy. 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 inpatient hospital services
billed with diagnosis code G93.41. Our reviewer says that the criteria for coverage have not been met. Our
physician reviewer found the enrollee was documented as alert and oriented x 3 upon presentation; the enrollee
continued to have intermittent confusion and was documented as oriented x 2 for the remainder of the stay. The
enrollee's mentation did not improve despite treatment for acute kidney injury and hyperammonemia. The
neurology consultant documented that the enrollee had confusion which is her baseline. The physician
documented in the progress notes and discharge summary that the encephalopathy was felt secondary to the
enrollee's dementia. The records provided do not support the diagnosis code G93.41 that was billed for the
inpatient hospital stay.
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 inpatient hospital services provided on June 16 - June 26, 2020, billed with diagnosis code G93.41.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the low osmolar contrast material used
during a magnetic resonance imaging (MRI) you had on August 2, 2021.
You asked the Plan to waive the coinsurance for the low osmolar contrast material. You say that you cannot
have an MRI without the dye, so there should not be a separate charge. The Plan denied your request. The Plan
says you were charged this separate cost sharing 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 20%
coinsurance for medical supplies.
You have been asked to pay 20% coinsurance for the low osmolar contrast material. Your contract explicitly
states that chemical agents used in certain diagnostic procedures have separate cost sharing applied. The low
osmolar contrast material falls within the medical 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 coinsurance for the low osmolar contrast material used during a magnetic resonance imaging
(MRI) you had on August 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).

You asked the Plan to pre-approve the direct skilled nursing services. The Plan denied your request. The Plan says the need for skilled nursing visits is not supported by the documentation.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 direct skilled nursing services. Our reviewer says that the requested, ongoing, home health skilled nursing services are not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs.

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 direct skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A6197) provided on February 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not
payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "P" under the Physician Fee
Schedule indicates that the there are no RVUs and no payment amounts for these services. No separate
payment is made for them under the fee schedule.
We looked at the file and Medicare rules. Code A6197 is assigned a status indicator of "P" under the Physician
Fee Schedule, which means that there are no RVUs and no payment amounts for this service. Separate payment
cannot be made. 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 (A6197) provided on
February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the metal crown (D2792) provided on June 30, 2021.
You asked the Plan to pay for the metal crown. You say that you would like reconsideration because you should only be responsible for a 50-70% coinsurance for this service. The Plan denied your request. The Plan says the cost sharing assessed is correct.
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 70% coinsurance for Dental Services. You have been asked to pay a 70% coinsurance plus the difference between the amount billed and the allowed amount for the metal crown. The metal crown falls within the Comprehensive Dental Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the metal crown (D2792) provided on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine surgery procedure (22899).
You asked the Plan to pre-approve a spine surgery procedure. You say that this procedure fills a treatment gap
for those patients that do not receive adequate relief from traditional conservative methods and don't have
instability to indicate that fusion is the appropriate treatment. The enrollee has tried and failed conservative
treatment without relief. The Plan denied your request. The Plan says the requested procedure is unproven and
not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 a spine surgery procedure. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the Intracept procedure remains experimental. More research is needed to
show safety and efficacy of the procedure to treat back pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a spine surgery procedure have not been met. Therefore, we decided that the
Plan does not have to pre-approve a spine surgery procedure (22899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 31, 2021.
You asked the Plan to pay for the limited exam. You say that you live on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says this type of exam is not covered by your dental benefit.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two additional intraoral x-rays (D0230) provided on August 2, 2021.
You asked the Plan to pay for the additional intraoral x-rays. You say that this was your only visit to the dentist this year, and you were told you were covered for the services you received. The Plan denied your request. The Plan says only one intraoral x-ray may be covered per calendar year. You received three intraoral x-ray films on the date in question. The first was covered in full, but you are responsible for the two additional x-ray images as these exceeded your Plan's frequency limitation for intraoral x-rays.
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 one procedure code for intraoral x-rays per calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral x-rays are requested in a frequency that exceeds what is covered under this benefit.
Documentation shows you received three intraoral images on August 2, 2021. The Plan paid for one image in full. The two additional images therefore exceed the frequency limitation of the benefit. Therefore, we decided that the Plan does not have to pay for two additional intraoral x-rays (D0230) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker evaluation you had on May 18, 2021.
You asked the Plan to waive the copayment for the remote pacemaker evaluation. You say that you didn't see this provider on this date. 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 $10 copayment for other diagnostic tests. You have been asked to pay a $10 copayment for the remote pacemaker evaluation. The medical records confirm that you had a remote pacemaker evaluation on this date. The remote pacemaker evaluation falls within the other diagnostic tests 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 remote pacemaker evaluation you had on May 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure codes 15004, 15271, 28234) provided to the enrollee on March 5, 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 the records do not support the services 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 the denied codes is: CPT 15004: Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children CPT 15271:
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area CPT 28234: Tenotomy, open, extensor, foot or toe, each tendon We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found in terms of CPT 15004, the medical records provided indicate that procedure 15725-59-79 was performed on the same date of service, during the same operative session. A modifier is allowed to unbundle the services providing the medical records support the use of the modifier. The medical records provided does not include sufficient documentation to support 15004-50-79 as a distinct, separate service, therefore, it is considered inclusive to 15725-59-79 and is not eligible for additional reimbursement. In terms of CPT 15271, the medical records provided do not include sufficient documentation to validate that an Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area was performed on March 5, 2021, therefore this service cannot be verified. In terms of CPT 28234, it was submitted without the required modifier to identify the toe the services were performed on. Therefore, the code cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure codes 15004, 15271, 28234) provided to the enrollee on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), diagnostic casts (D0470), and crown (D2740) provided on June 29, 2021.  You asked the Plan to pay for the first intraoral periapical x-ray, diagnostic casts, and crown. You say that you did not receive reimbursement for these services and feel they should be covered. The Plan denied your request. The Plan says the maximum dental benefit has been met for the 2021 plan year.  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 Plan offers up to $400 every year for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while re-processing the claim for the June 29, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), diagnostic casts (D0470), and crown (D2740) provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on July 9,
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 the services are 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 rendered on
July 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation from December 8, 2021, forward.
You asked the Plan to pre-approve inpatient substance abuse rehabilitation from December 8, 2021, forward. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that in order for an inpatient hospital stay for alcohol rehabilitation to be covered under Medicare it must be medically necessary for the care to be provided in the inpatient hospital setting rather than in a less costly facility or on an outpatient basis 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 substance abuse rehabilitation from December 8, 2021, forward. Our reviewer says that based upon the records provided the enrollee does not meet criteria for inpatient substance abuse rehabilitation from December 8, 2021, forward. Our physician reviewer found the enrollee was found to deny any distress or acute withdrawal. She is not a danger to herself or others, does not have auditory or visual hallucinations and is able to care for herself. The enrollee could be treated in a lesser restrictive environment. 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 substance abuse rehabilitation from December 8, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation from December 8, 2021, forward