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

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 18, 2020 to August 21, 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 submitted records do not support the billing of diagnosis code N17.9 and DRG 330.  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 N17.9 (acute kidney failure, unspecified) and DRG 330 (major small and large bowel procedures with CC). 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 these services. Our reviewer says that the submitted records do not support the billing of diagnosis code N17.9 and DRG 330. Our physician reviewer found the enrollee was admitted to the hospital for an elective ileostomy reversal. The enrollee had a previous colorectal anastomosis and diverting loop ileostomy secondary to rectal cancer. The review indicates that one or more of the billed diagnosis were not supported by the clinical records and/or did not impact the clinical resource utilization. The review has determined that  the records did not support the billing of diagnosis code N17.9 (acute kidney failure, unspecified) and DRG 330 (major small and large bowel procedures with CC).   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 hospital services rendered from August 18, 2020 to August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2784) provided on October 8, 2021.

You asked the Plan to pay for the eyeglasses. You say that your prescription changed since last year and you needed new glasses. The Plan denied your request. The Plan says routine eyewear is covered up to $240 once every 24 months. You previously purchased eyeglasses in January of 2020, which were covered at that time.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $240 once every 24 months. 

We looked at the file and the Plan's rules. The record shows that you last used this benefit less than 24 months before the date in question. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2784) provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), initial periapical x-ray (D0220),
and additional periapical x-rays (D0230 x 2) provided on September 22, 2021.
You asked the Plan to pay for the dental services. You say that you do not know what codes the dentist uses.
You say that it does not make sense that only some x-rays are covered. You also say that you cannot afford to
pay this bill. The Plan denied your request. The Plan says prophylaxis is covered twice per plan year. The Plan
says that the frequency limit has been exceeded. The Plan also says that 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 and prophylaxis is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you received on
January 13, 2021, and May 19, 2021. Additionally, periapical x-rays are not among those covered under this
benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), initial periapical
x-ray (D0220), and additional periapical x-rays (D0230 x 2) provided on September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from April 12, 2021, through
April 30, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says based on Medicare guidelines, the SNF services you are requesting do not meet the requirements for retroactive approval.
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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. The services in the nursing facility appear custodial. 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 pay for SNF services provided from April 12, 2021, through April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered on February 4, 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 Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia services rendered on February 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) coded 70551 provided on September 24, 2021.
You asked the Plan to pay for the MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 70551 is magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material.
We find that CPT code 70551 is not supported in the medical record. Specifically, this code was billed with a primary diagnosis of F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance). Codes titled "in diseases classified elsewhere" are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. Since this is not how this code was billed, these services are not payable as billed. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) coded 70551 provided on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).  You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no trial and failure of portable oxygen tanks.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease, obstructive sleep apnea, and severe obesity. The enrollee has been provided with portable oxygen tanks for mobility within the home. The medical records do not indicate why a portable oxygen concentrator is needed, and why the portable tanks are insufficient. Medicare criteria for coverage of a POC include documentation that oxygenation is sufficient using an oxygen conserving device.  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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 22,
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 provider did not bill as required by Medicare coding regulations.
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 70450
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on August 22, 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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and does not require transfer to an LTACH.
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. You appear to be tolerating weaning trials and require only short-term additional acute care hospital services including ongoing weaning that can safely be administered at the current facility for the time being. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Zoster (shingles) vaccine received on June 23, 2021.  You asked the Plan to pay for the vaccine. You say that you are under care for many issues, and this was recommended by your doctor. The Plan denied your request. The Plan says this denial is appropriate given the clinical scenario.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine received on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the eyeglasses provided on November
16, 2020.
You asked the Plan to pay an additional amount for the eyeglasses. You say that you would like reconsideration
because you have worn glasses for 30 years and this should be a covered benefit. The Plan denied your request.
The Plan says the Plan has paid the maximum amount for this benefit and you are responsible for the additional
cost.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $175 per pair of eyeglasses including upgrades.
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we
decided that the Plan's rules for coverage of the eyeglasses have not been met. Specifically, the record indicates
that the Plan has paid the maximum amount of $175 towards this benefit. Per your contract with the Plan, you
are responsible for any charges in excess of the maximum benefit. Therefore, we decided that the Plan does not
have to pay an additional amount for the eyeglasses provided on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 19, 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 testing is not covered.
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.
The test at issue in this appeal, fluorescence in-situ hybridization (FISH) testing, was requested solely for
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that
the Plan does not have to pay for the laboratory services rendered on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown
provided on January 19, 2021, and the porcelain crown (D2740) provided on March 29, 2021.
You asked the Plan to pay for the dental services. You say that your enrollment guide indicates there is no
deductible and no copay. You also say that you had close to 35% of your benefits withheld. The Plan denied
your request. The Plan says the provider in this case is out of network. The Plan says that out of network
services are paid based on the allowed amount. The Plan also says that out of network dentists may bill you for
any amount greater than what the plan paid.
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 and the services are listed as covered,
the provider in this case is out of network. The Evidence of Coverage states that if you choose to see an out of
network dentist you might be billed for any amount greater than what the plan pays, even for services with a $0
copayment. The record shows that the Plan paid 100% of the allowed amount for the services in this case. You
are responsible for the different between what the provider charges and the plan pays. Therefore, we decided
that the Plan does not have to pay for the prefabricated post and core in addition to a crown provided on
January 19, 2021, and the porcelain crown (D2740) provided on March 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June
8, 2021, by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says
the service was performed and referred by non-participating providers. The Plan says that the service was not
authorized by the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336)
provided on June 8, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July
15, 2021.
You asked the Plan to pay for the dental service. You say that you changed dentists as your previous dentist
was out of network. You say that The Plan denied your request. The Plan says 1 comprehensive oral evaluation
is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 and the service is listed as covered, the
frequency limit has been exceeded.
The record shows that the Plan paid for a comprehensive oral evaluation that you received on January 21, 2021.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150)
provided on July 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of arm or leg veins (93971)
provided on May 7, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that this should be a $25 copayment.
The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was
assessed in accordance with your contract. Ultrasounds require a $160 copayment. Because the Plan's allowed
amount (discounted rate) for the service in this case is less than your copayment amount, you are being asked
to pay a lower 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 $160
copayment for outpatient radiological diagnostic services.
You have been asked to pay a $105.85 copayment for the ultrasound. An ultrasound falls within the outpatient
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 waive the copayment for
the ultrasound of arm or leg veins (93971) provided on May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure code 36215) provided to the enrollee on June 28, 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 denied code is not supported in the medical records submitted.

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 36215 is "Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family." 

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 the procedure reports that the procedures were performed through "Straight Arm Graft." Therefore, this procedure would not be reported separately.

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 code 36215) provided to the enrollee on June 28, 2021.