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

 We decided that the Plan does not have to pay for the chemotherapy services provided on May 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient services. You say that the practice where the enrollee is in active treatment was acquired by another. You say that the facility has requested in network participation. You also say that the services should be covered. The Plan denied your request. The Plan says the services provided were not urgent or emergent in nature. The Plan also says that there was no authorization on file for the services provided.  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 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 chemotherapy services provided on May 11, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided from February 13, 2020, to February 18, 2020.  You asked the Plan to pay for the services provided. You say that it is imperative to respect the clinical judgement of the physician. The Plan denied your request. The Plan says the diagnosis was not clinically supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with a primary diagnosis of A41.9 defined as sepsis, unspecified organism, and a secondary diagnosis of J96.01 defined as acute respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services provided. Our physician reviewer found that the enrollee presented to the emergency room with difficulty breathing, cough productive of sputum, fever, and chills. Her vital signs improved with treatment. Her creatinine, total bilirubin and platelets were within normal limits. The documentation did not support respiratory failure. As noted, although the provider documented sepsis and acute respiratory failure, reasonable support within the health record must be present for that diagnosis. The review has determined that the use of the billed diagnosis was not supported by the medical records.  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 provided from February 13, 2020, to February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an echocardiography procedure (93306) provided on June 17, 2021.  You asked the Plan to waive the copayment for an echocardiography procedure. You say that the procedure at issue was useless and you do not feel you should pay. The Plan denied your request. The Plan says the correct copayment was 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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility).   You have been asked to pay a $10 copayment for an echocardiography procedure. An echocardiography procedure falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for an echocardiography procedure (93306) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided on April 14, 2021.  You asked the Plan to pay for the hearing aids. You say that you were not informed you must use plan providers for the hearing aid benefit. You say that the claim should be reprocessed for reimbursement. The Plan denied your request. The Plan says you did not use a plan provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from Plan providers.   We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immunization services rendered on September 11, 2020 to September 30, 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 provider is not Medicare-certified.  The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.  We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the dates of service at issue. Therefore, we decided that the Plan does not have to pay for the immunization services rendered on September 11, 2020 to September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the hearing aids provided on May 14, 2021.  You asked the Plan to pay for the hearing aids. You say that you sent the invoice and are asking for the $1,000 reimbursement. The Plan denied your request. The Plan says the $1,000 allowance was paid.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays $1,000 for up to two hearing aids every two calendar years.   We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the hearing aids have not been met. Specifically, the Plan paid $1,000 toward the hearing aids on September 17, 2021. Therefore, we decided that the Plan does not have to pay more for the hearing aids provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) services to the lumbar spine.  You asked the Plan to pre-approve RFA services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this service has already met the frequency limit for the lumbar spine region.  The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region, no more than 2 radiofrequency sessions will be reimbursed per rolling 12 months.   We looked at the file and Medicare rules. In this case, two RFA sessions have already occurred during the rolling 12-month period. Based on this information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA) services to the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection of a major joint or bursa (20611) provided on August 10, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $325 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.    You have been asked to pay $316.66 for the Medicare-covered surgery provided at an outpatient hospital. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 arthrocentesis, aspiration and/or injection of a major joint or bursa (20611) provided on August 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound (93306), provided on August 6, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $85 copayment for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $85 copayment for the ultrasound. This service falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for the ultrasound (93306), provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the crown for tooth # 20.  You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says your records must show over 50% of the tooth is lost.  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 crown when the services are medically necessary and reasonable.   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 crown. Our reviewer found that the amount of missing structure on the provided x-ray was about 30%, and it was not made clear how large the subsequent fracture of the structure was. Our reviewer says that there is not enough missing structure to require a full coverage crown as the final restoration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth # 20.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 6, 2021.  You asked the Plan to pay for this should be paid for.. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of end-stage renal disease (ESRD).  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. ESRD-related laboratory services are not able to be reported separately, according to Medicare coding guidelines.  In this case, the CPT Code Manual definition of the denied codes is:  CPT 82310:  Calcium; total  CPT 82728:  Ferritin  CPT 83540:  Iron  CPT 83550:  Iron binding capacity  CPT 84100:  Phosphorus inorganic (phosphate)  We find that CPT code  is not supported in the medical record. Specifically, the records clearly show that these laboratory services were related to the treatment of end-stage renal disease (ESRD). Therefore, these services cannot be reported separately by the laboratory, and are the responsibility of the dialysis center. Based on this information, we decided that Medicare rules for coverage of this should be paid for. have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 6, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on July 28, 2021.  You asked the Plan to waive the copayment for emergency care. You say that the doctor should have informed you what to expect from the extent of your injuries so you would not have had to return a second time. 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 $75 copayment for emergency care.   You have been asked to pay a $75 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Genesight testing (81479) provided on March 25, 2021.  You asked the Plan to pay for Genesight testing. You say that this is a covered service. The Plan denied your request. The Plan says this was not necessary.  The Plan must follow Medicare rules. Medicare rules say that in order for Pharmacogenomics Testing services to be covered, the patient's medical record must clearly reflect that the criteria listed in the rules section have been met.  We looked at the file and Medicare rules. The submitted medical records do not include records from the ordering provider demonstrating that the criteria for coverage have been met and that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture (D5214).  You asked the Plan to pre-approve a partial lower denture. You say that these dentures are medically necessary. The Plan denied your request. The Plan says your masticatory function does not appear to be severely impaired, and there are not a sufficient number of missing teeth in the mandibular (lower) arch to meet the criteria for coverage of the lower denture.  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 a partial lower denture when the services are medically necessary and reasonable.   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 partial lower denture. Our reviewer says that the criteria for coverage for a mandibular removable partial denture have not been met, and it is not medically necessary. Our physician reviewer found upon review of the provided records, you are missing one mandibular tooth (#18), which has an opposing tooth. A maxillary (upper) partial denture replaces the missing maxillary teeth. It appears that with the maxillary partial and the natural mandibular teeth that are present, the enrollee has adequate bilateral masticatory function.  A partial denture replacing missing tooth #18 is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the exploration of spinal fusion rendered on April 26, 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 procedure code 22830 is 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 22830 (exploration of spinal fusion) and 22633 (lumbar spinal fusion, combined). Code 22830 is a column II code with a modifier indicator of 1 when billed with column I code 22633. Code 22830 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 exploration of spinal fusion rendered on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110), periodic oral evaluation (D0120), and bitewings (D0274), provided on August 18, 2021.  You asked the Plan to pay for the prophylaxis, periodic oral evaluation, and bitewings. You say that the services should be covered. The Plan denied your request. The Plan says you received these services out-of-network.  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. Specifically, supplemental dental services are not covered when obtained out-of-network. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), periodic oral evaluation (D0120), and bitewings (D0274), provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 6, 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 as billed.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve personal care services (T1019).  You asked the Plan to pre-approve personal care services. You say that this is necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested services are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 17, 2021, to August 28, 2021.

You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee improved with skilled care. The Plan also says that the enrollee had returned to baseline and did not require daily skilled needs.

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 the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

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 SNF care have not been met. Specifically, the file shows that the enrollee did not receive daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 17, 2021, to August 28, 2021.