Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for four primary care visits (99214, 99215)
provided from May 26, 2021, to May 29, 2021.
You asked the Plan to waive the copayments for the primary care visits. You say that you were under hospital
observation care at the time and there should not be a separate copayment for the physician visits. The Plan
denied your request. The Plan says the correct copayments were applied.
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 $5
copayment for Primary Care visits.
You have been asked to pay $20 (four $5 copayments) for four primary care visits. 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 copayments for four primary care visits (99214, 99215) provided from May 26, 2021, to May 29,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus palatinus (D7472).
You asked the Plan to pre-approve removal of torus palatinus. You say that the service is necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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 pre-approve removal of torus palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and cleaning (D1110) provided on June 24, 2021.
You asked the Plan to pay for a periodic oral evaluation and cleaning. You say that there were problems with your previous services. The Plan denied your request. The Plan says this exceeds the coverage limit.
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 services at issue are covered once every six months. The record shows that you previously received these services on February 11, 2021.
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and cleaning (D1110) provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on March 8, 2021.

You asked the Plan to pay for the dental services. You say that in February 2020, you called the plan to get a list of in network dentists. You say that you were also advised that you had dental coverage. You say that after your appointment, you were advised by a plan representative that they forgot to update your dental coverage. You also say that you received a bill for $212. The Plan denied your request. The Plan says there are no routine dental benefits offered with the plan. The Plan also says you were not enrolled in a dental plan on the date of service in this case.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 8, 2021.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362, and L36523 to support their denial. However, LCD L36139, L36129, L36362, and L36523 are not valid for the provider's billing state of Texas for the correct jurisdiction. Therefore, we are unable to use LCD L36139, L36129, L36362, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that your medical condition is eligible for inpatient therapy. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.

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 that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on May 5, 2021.
You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that you went for a dental exam and x-rays were taken for a bad tooth. You say that you left gaining nothing and they didn't contact the insurance to see what would be paid. The Plan denied your request. The Plan says the services are not covered benefits.
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 and intraoral x-ray provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230 x 2) provided on April 21, 2021.
You asked the Plan to pay for the dental services. You say that your dentist advised that periapical x-rays are standard x-rays for the front teeth. You say that in past years, these x-rays have been covered. You say that your husband received the same x-rays, and they were not denied. You also say that you do not understand why these x-rays are not covered. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services.
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 periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230 x 2) provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 25, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit for the evaluation and management (CPT code 
99345) provided to the enrollee on February 9, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the service. You say that it was impossible to obtain authorization, due to the 
enrollee misleading you with the incorrect insurance information. The Plan denied your request. The Plan says 
this provider is out-of-network, the services were not referred by a network provider, and the services were not 
urgent or emergent, nor were they approved in advance. 

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 home visit for the evaluation and management 
(CPT code 99345) provided to the enrollee on February 9, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 15, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost share the office visit provided on March 11, 2021 and April 2, 2021.

You asked the Plan to waive the cost share the services provided. You say that your understanding is that you do not have a deductible with your plan. The Plan denied your request. The Plan says that the claims were processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.

The Plan says you must pay a deductible and coinsurance for the services provided. Based on the Plan contract, however, you do not have a deductible or cost share for physician services. Therefore, we decided that the Plan has to waive the cost share the office visit provided on March 11, 2021 and April 2, 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 pay for the home health services provided to the enrollee from
March 29, 2021, to March 31, 2021.
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says a corrected claim is needed.
The Plan must follow Medicare rules. The rules say that home health services must be billed correctly.
A review of the case file shows that the correct type of bill was not submitted in this case. 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 home health services provided to the enrollee from March 29,
2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 and the bronchoscopy 
services coded 31622 provided from February 15, 2020 to February 18, 2020. 
 
You asked the Plan to pay for the critical care services and the bronchoscopy services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 99291 and 31622 is critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes.

The CPT Code Manual definition of code 31622 is Bronchoscopy, rigid or flexible, including fluoroscopic 
guidance, when performed; diagnostic, with cell washing, when performed (separate procedure). 
 
We find that CPT codes 99291 and 31622 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of critical care note for the billed dates of service; 
therefore, code 99291 cannot be verified for dates of service February 15, 2020 to February 17, 2020. The 
documentation submitted did not include documentation of bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed; therefore, code 31622 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the critical care 
services and the bronchoscopy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the critical care services coded 99291 and the bronchoscopy services coded 31622 provided from 
February 15, 2020 to February 18, 2020.
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 you need inpatient rehab and are willing and able to
complete the 15 hours of therapy per week. The Plan denied your request. The Plan says the criteria for
admission to an IRF are not met, and you can safely receive the services you need in a lower level of care.
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87631, 87496, 87498, 87541, 87640, 87798, and 87532 provided on January 11, 2021.
You asked the Plan to pay for the laboratory services. 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.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87631, 87496, 87498, 87541, 87640, 87798, and 87532 are not supported in the medical record. Specifically, the documentation shows that these codes were submitted for a and COVID19 Molecular Pathogen Panel. The submitted documentation indicates more than five (5) targets. There is a more appropriate code to describe the services provided. Multiplex polymerase chain reaction respiratory viral panels of six or more pathogens are non-covered. The pathogen targets that compose the panels are determined by the
manufacturers that make them, and do not represent specific pathogens that cause a common syndrome, or the organisms that commonly are found in a specific sample type or enrollee population or reflect seasonal variations. The fixed nature of these multiplex panels includes pathogens that cause infections different enough that simultaneous testing for these pathogens should be rare. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87631, 87496, 87498, 87541, 87640, 87798, and 87532 provided on January 11, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) provided on May 16, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you cannot afford this payment. The Plan denied your request. The Plan says this processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for an emergency room visit. 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 an emergency room visit (99285) provided on May 16, 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
was admitted with acute hypoxic respiratory failure and sepsis due to pyelonephritis from obstructive uropathy. 
The enrollee is clinically improving and remains at baseline mental status. The enrollee continues to receive 
acute care services, and these have not been denied. 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. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation
device.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that electro-acupuncture devices used for stimulation of auricular
acupuncture points are noncovered.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electroacupuncture
devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to
pre-approve placement of an auricular peripheral nerve stimulation device