Persius/hicric huggingface dataset:
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 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 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 medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.  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: Practitioner Services
Decision: Partially Favorable

 You asked the Plan to pay for ultrasound guidance and needle placement. You say that this was medically necessary and was billed with appropriate modifiers. The Plan says that the denial of payment for these services is correct, because code 36000 is always bundled for payment and is not separately payable.  We decided that the Plan has to pay for ultrasound guidance.   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. The record shows that ultrasound guidance code 76937 was billed on this claim and that payment for this code was denied by the Plan. The Plan did not provide any rationale for this denial, nor any evidence to support that denial of payment for this code - as it has been billed - is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for ultrasound guidance.   We also decided that the Plan does not have to pay for needle placement.  The Plan follows Medicare rules. Medicare rules state that code 36000 is always bundled for payment, and if it is covered the payment for it is subsumed by the payment for the services to which it is incident.   This code is always bundled for payment and is not separately payable. Therefore, we decided that the Plan does not have to pay for needle placement.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for inpatient hospital services you received from August 4, 2021, to August 7, 2021.  You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you were told that your charge would only be $175. 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 $175 copayment per day for days 1-3 for inpatient hospital services.   Records show that you were in the hospital for three days.  You were charged a $175 copayment per day, for a total of $525. 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 reduce the copayment for inpatient hospital services you received from August 4, 2021, to August 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion pump refill kit (A4220), the Hydromorphone (J1170), the unclassified drugs (J3490), and Baclofen (J0475) provided on August 12, 2020.
You asked the Plan to pay for codes A4220, J1170, J3490, and J0475. 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.
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 A4220 is a column II code to column I code 62370.
The drug codes reported on this claim (J1170 and J0475) refer to a pre-filled compounded drug. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
Medicare rules also say that providers must report the actual number of units provided for each procedure code. We find that code 80 units of code J3490 are not supported in the medical record.
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 infusion pump refill kit (A4220), the Hydromorphone (J1170), the unclassified drugs (J3490), and Baclofen (J0475) provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on June 21, 2021.  You asked the Plan to pay for the SelectMDx testing (81479). 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.  The Plan must follow Medicare rules. Medicare rules say that SelectMDx has been deemed investigational. Code 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not considered medically necessary and is therefore not covered. Based on this information, we decided that Medicare rules for coverage of the SelectMDx testing (81479) have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services (D0140, D1999, and D9440) provided on August 14, 2021.  You asked the Plan to pay for dental codes D0140, D1999, and D9440. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D0140 is covered only once per plan year. You previously received dental code D0140 on July 20, 2021. Dental codes D1999 and D9440 are not covered under the Plan's supplemental 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, dental codes D1999 and D9440 are not among those covered under this benefit. The Plan contract clearly says that dental code D0140 is covered only once per plan year. The file shows that you previously received dental code D0140 on July 20, 2021. Therefore, we decided that the Plan does not have to pay for the dental services (D0140, D1999, and D9440) provided on August 14, 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 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 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 medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.  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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic colonoscopy (45378) provided on May 28, 2021.  You asked the Plan to pay for code 45378. 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. The rule say it is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.  In this case, the file shows that code 45378 was billed with diagnosis codes Z12.11 and K64.4. These diagnosis codes are not listed as covered diagnosis codes that support medical necessity. Based on this information, we decided that Medicare rules for coverage of code 45378 have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic colonoscopy (45378) provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for to pay for a Zoster and TDAP vaccines provided on December 17, 2020.  You asked the Plan to pay for these vaccines under Medicare Part B. You say that these vaccines should be covered by the Plan. The Plan denied your request. The Plan says these vaccines are not covered under Medicare Part B.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these vaccines under Medicare Part B. The Plan follows the same rules. These vaccines were preventative and therefore would not be covered under Medicare Part B. Therefore, we decided that the Plan does not have to pay for to pay for a Zoster and TDAP vaccines provided on December 17, 2020.   Benefits for these vaccines under Medicare Part B may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the transthoracic echocardiography (TTE) you received on May 4, 2021.  You asked the Plan to reduce the copayment for the TTE. You say that this should be considered a non-radiological diagnostic service, which should only have a $20 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 $110 copayment for radiological diagnostic services.   You have been asked to pay a $110 copayment for the TTE. A TTE uses a transducer that is a type of ultrasound.  Because this equipment is used, the TTE falls within the radiological diagnostic 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 reduce the copayment for the transthoracic echocardiography (TTE) you received on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided June 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the bitewing x-rays, periodic oral exam and dental cleaning. You say that you would like the services covered. The Plan denied your request. The Plan says OON services are not covered by the Plan.  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 covers the bitewing x-rays, periodic oral exam and dental cleaning when the services are provided by a network provider.  We looked at the file and Medicare rules. In this case the services were provided out-of-network. Based on this information, we decided that the Plan's rules for coverage of the bitewing x-rays, periodic oral exam and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided June 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided May 4, 2021, through  May 7, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that based on the information received, it does not support an acute inpatient stay.  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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the medical record showed that at the time of inpatient admission the admitting physician reasonably expected that 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided May 4, 2021, through May 7, 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional 17 home health skilled nursing visits (plan approved 10).  You asked the Plan to pre-approve the additional home health visits. You say that you feel that this is necessary. The Plan denied your request. The Plan says the number of requested visits exceeds your medical need.  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 additional home health visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the enrollee is to receive wound care thrice weekly. At least some of this wound care is being provided by a wound clinic. As such, it is not necessary for a skilled nurse to visit the enrollee thrice weekly. The enrollee does not have other documented skilled nursing needs (i.e. IVs, new ostomy). As such, the quantity of requested of home health nursing visits is not medically necessary or reasonable.  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 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 17 home health skilled nursing visits (plan approved 10).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided on July 21, 2021.  You asked the Plan to waive the copayment for extracapsular cataract removal. You say that you thought that there was no charge for the service. 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities.  You received extracapsular cataract removal at an outpatient hospital facility on July 21, 2021. Extracapsular cataract removal is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment.   You have been asked to pay a $275 copayment for extracapsular cataract removal. Extracapsular cataract removal falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 extracapsular cataract removal provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Ultrasonic guidance for needle placement (76942) provided on July 29, 2021.  You asked the Plan to pay for code 76942. 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 76942 is a column II code to column I code 36478. 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 (76942) provided on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 30, 2021.  You asked the Plan to pay for the laboratory services. 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.  The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.    We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible applied to pacemaker testing services you received from an out-of-network cardiologist on May 30, 2018.  You asked the Plan to waive the deductible applied to the out-of-network cardiology services. You say that you don't go to this office any more, and you returned all equipment to them. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.  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 out-of-network specialist services. falls within the benefit category out-of-network specialist services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to out-of-network specialist services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network cardiology services were received on May 30, 2018. Therefore, we decided that the Plan does not have to waive the deductible applied to pacemaker testing services you received from an out-of-network cardiologist on May 30, 2018.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide (HHA) services.  You asked the Plan to pre-approve the HHA visits. You say that you feel that HHA services are needed to alleviate pressure on your spouse to care for you. The Plan denied your request. The Plan says you do not meet Medicare criteria for HHA services.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the HHA visits. Our reviewer says that the documentation does not show that the coverage rules for HHA care are met. Our physician reviewer found the enrollee has received some home health physical therapy; however, there is insufficient documentation to show that concomitant HHA services are medically necessary and reasonable to assist in the treatment of the enrollee's chronic mobility issues. The requested HHA services appear to be long-term and custodial.   As such, the requested HHA services are not medically necessary, reasonable or coverable.  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 HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services.