Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan has to pay for the WATS-3D biopsy provided on January 4, 2021.
You asked the Plan to pay for the WATS-3D biopsy. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 WATS-3D biopsy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's available record supports the high likelihood of Barrett's esophagus, and thus meets the American Society of Gastrointestinal Endoscopy (ASGE) guidance relative to medically necessary use of WATS-3D in this case. 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 WATS-3D biopsy have been met. Therefore, we decided that the Plan has to pay for the WATS-3D biopsy provided on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital services provided from May 21, 2021, to May 23, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you do not believe the second night of hospitalization was medically necessary because the enrollee was able to walk around the room and didn't need physical therapy. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment per day for days 1-5 for inpatient hospital care. The enrollee has been asked to pay a $350 copayment per day each of the two days he was an inpatient. This copayment applies even if you disagree with the length of the stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the inpatient hospital services provided from May 21, 2021, to May 23, 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 continued management can be provided in the acute care hospital until the enrollee's course of care is complete.
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 on chronic hypoxic respiratory failure due to coronavirus pneumonia. The record indicates that the enrollee has multiple chronic medical problems and is deconditioned. The record indicates that you believe the enrollee can go to a subacute facility once she completes her hospital course. 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 she 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet radiofrequency ablation (RFA).
You asked the Plan to pre-approve facet radiofrequency ablation (RFA). You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that no more than two radiofrequency sessions will be
reimbursed per rolling 12 months.
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 facet radiofrequency ablation (RFA).
Our reviewer says that the documentation does not support that the requested services are medically reasonable
or necessary. Our physician reviewer found the enrollee has undergone multiple sessions (five sessions) of
lumbar RFA within the past 12 months. The frequency limitation for each covered spinal region no more than
two (2) radiofrequency sessions will be reimbursed per rolling 12 months." A session is a time period, which
includes all procedures that are performed during the same day. This means the enrollee has exceeded the
benefit limit for the requested services. Therefore, the enrollee does not meet criteria for the requested 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 facet radiofrequency ablation (RFA) have not been met. Therefore, we decided
that the Plan does not have to pre-approve facet radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

You asked the Plan to pay for the complete series of intraoral x-rays. You say that the receptionist at the 
provider's office told you the service would be covered by your insurance. You also say that you were at the 
mercy of the provider and believed the provider that the service would be covered. The Plan denied your 
request. The Plan says this service is 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. 
 
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 
complete series of intraoral x-rays (D0210) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2020 by a non-participating provider.
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 were rendered by a non-participating 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 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 laboratory services provided on September 30, 2020 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the facet injection rendered on April 19, 
2021. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance 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 50% 
coinsurance for out-of-network diagnostic procedures and tests at an outpatient hospital.  
 
Review of the file shows that you received a diagnostic facet injection on April 19, 2021. You have been asked 
to pay a 50% coinsurance for these services. These services fall within the out-of-network diagnostic 
procedures and tests at an outpatient hospital benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the facet injection rendered on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 18, 
2020 to January 22, 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 DRG 189 and diagnosis code J96.21. 
 
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 DRG 189 (pulmonary edema and respiratory failure 
- market size, prevalence, incidence, quality outcomes, top hospitals & physicians) and diagnosis J96.21 (acute 
on chronic 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 
these services. Our reviewer says that the submitted records do not support the billing of DRG 189 and 
diagnosis code J96.21. Our physician reviewer found the submitted documentation is inconsistent and unclear 
regarding a diagnosis of acute and chronic respiratory failure with hypoxia for the enrollee. Although acute and 
chronic respiratory failure with hypoxia is documented in the history and physical, progress notes, and 
discharge summary, the medical records do not support this. The emergency department note indicates the 
admission was for advanced chronic obstructive pulmonary disease (COPD) exacerbation. The pulmonary 
notes from January 19, 2020 state advanced COPD cor pulmonale congestive heart failure. The records 
therefore do not support the billed DRG and diagnosis code.  
 
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 January 18, 2020 to January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye examination including refraction (S0620) 
provided on June 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a routine eye examination. You say that you are very unhappy with your Plan 
because it did not cover a vision service. You also say you were told at least a portion would be covered if the 
provider was out of network. The Plan denied your request. The Plan says the diagnosis billed by the provider 
is for a routine service. The Plan also says that there are no benefits when using an OON provider. 
 
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 when The Plan covers these services when it is provided by an in-
network provider. 
 
We looked at the file and the Plan's rules. The records show that the service at issue was provided by an OON 
provider. This service is not covered by the Plan when provided by an OON provider. Based on this 
information, we decided that the Plan's rules for coverage of a routine eye examination have not been met. 
Therefore, we decided that the Plan does not have to pay for a routine eye examination including refraction 
(S0620) provided on June 21, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) provided on May 21, 2021.
You asked the Plan to pay for a wig. You say that the item at issue is a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) provided on May 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0428) provided 
on April 1, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the copayment has processed correctly in this 
case. 
 
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 $260 
copayment for ambulance services.  
 
You have been asked to pay a $226.97 copayment for the ambulance services. These services fall within the 
ambulance services benefit category. You have been charged an amount that is less than the required $260 
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 ambulance services (A0428) 
provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy procedure (63047-59 and 63048) provided 
on May 11, 2021. 
 
You asked the Plan to pay for the laminectomy procedure. You say that the documentation submitted supports 
the services as billed. The Plan denied your request. The Plan says the codes as billed cannot be verified with 
the documentation submitted. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 laminectomy procedure Our reviewer 
says that the documentation submitted does not support the codes as billed. Our physician reviewer found the 
medical records provided do not include sufficient documentation to validate that the laminectomy, 
facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or 
nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar performed on May 11, 
2021, was performed as a distinct/ separate service from CPT 22633 that was performed on the same day by 
the same physician/practice, therefore the use of a 59 modifier to unbundle this service from 22633 would not 
be appropriate and there is no additional reimbursement for 63047. 
 
Regarding code 63048, CPT 63048 is an add-on code.  Medicare rules state that an add-on code is only eligible 
for reimbursement if the preceding primary procedure code is eligible for reimbursement. In this case, CPY 
63047 (primary) is not eligible for reimbursement as the medical records submitted did not sufficiently validate 
the use of Modifier 59 to unbundle 63047 from CPT 22633, therefore, add-on code 63048 is not eligible for 
reimbursement. 
 
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 laminectomy procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for the laminectomy procedure (63047-59 and 63048) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 28, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you thought that these services were included in the $1,080 that you already paid. You say that you were told the insurance billed you extra for these services. You also say that the insurance representative that you spoke with did not tell you this would be extra. The Plan denied your request. The Plan says panoramic x-ray is not listed as a covered service. The Plan also says that you were advised prior to the date of service that the only covered x-rays were bitewing x-rays.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the panoramic x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported crown (D6066) provided on May 11, 
2021. 
 
You asked the Plan to pay for the implant supported crown. You say that the dentist's charge was only for a 
crown, not for the insertion of an implant. You also say that you would like to be reimbursed for the cost of this 
crown. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. 
 
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 
implant supported crown (D6066) provided on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the documentation provided, the 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can 
be provided at a lower level of care. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for overnight medical services (99053) provided on June 9, 2021.
You asked the Plan to pay for overnight medical services. You say that this should be covered. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Code 99053 has a status code of B, meaning payment for this code is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of overnight medical services have not been met. Therefore, we decided that the Plan does not have to pay for overnight medical services (99053) provided on June 9, 2021.