Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two skilled nursing services.
You asked the Plan to pre-approve the skilled nursing services. The Plan denied your request. The Plan says the medical records submitted on your behalf do not show that more skilled nursing visits are needed in addition to what you already have approved.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the skilled nursing services. Our reviewer says that the additional skilled nursing services are not medically reasonable and necessary for you. Our physician reviewer found there is no documentation that skilled nursing services are required beyond what have already been approved by the Plan. Our reviewer also found that the records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve two skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker (E1399).
You asked the Plan to pre-approve the upright walker. You say that the upright walker is medically necessary. The Plan denied your request. The Plan says a standard walker will meet the enrollee's needs.
The Plan follows Medicare rules. Medicare rules say that an upright walker is covered when 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 pre-approve the upright walker. Our reviewer says that the requested walker is not medically necessary. Our physician reviewer found the patient's physician did not document the reason a standard walker would not be appropriate for this patient which is required. Based on the records, a standard walker would meet the enrollee's needs.
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 upright walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 18, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does
not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on August 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided to the enrollee on August 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $80 copayment charged for ambulance transport.
You asked the Plan to waive this copayment. You say that you were told you would not have to pay for this transport from one facility to another by the nurse and the doctor. The Plan denied your request. The Plan says this copayment was applied based on your Plan contract.
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 $80 copayment for each one-way ambulance transport. The physician and the nurse at the facility do not have to authority to advise you on the waiving of a copayment. This is a contractual obligation between you and the Plan. The Plan paid for this transport apart from the required copayment. 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 $80 copayment charged for ambulance transport provided on July 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided from June 24, 2021, to September 9, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have 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 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 out of network outpatient mental health care provided from June 24, 2021, to September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no need for multiple power option features including power elevating leg rests and combination tilt/recline.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records from the treating provider, there is no documentation that the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is no documentation that the patient's mobility deficit cannot be helped by the use of a manual wheelchair. There is no documentation that the enrollee can safely operate a power mobility device. There is no documentation that the enrollee meets
Medicare criteria for coverage of the various accessories. Records from her treating provider do no document spasticity, need for urinary self-catherization, pressure ulcers or lower extremity edema which would necessitate the requested accessories. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a partial lower denture (D5226).
You asked the Plan to pre-approve the partial lower denture. You say that you were told this denture would be covered, and you cannot eat properly without it. The Plan denied your request. The Plan says that you have eight back teeth that touch, which is generally considered adequate for functional purposes. The partial lower denture is not medically necessary.
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 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 denture. Our reviewer says that the documentation provided meets the criteria for coverage for a mandibular removable partial denture (D5226). Our physician reviewer found that a removable partial lower denture is requested. The Plan has previously pre-approved a removable partial upper denture and has denied the lower denture as not medically necessary. The Plan says that generally, eight natural or prosthetic teeth touching are generally considered adequate for functional purposes. However, because the enrollee is missing mandibular teeth bilaterally, it is the opinion of our medical reviewer that a partial denture is medically reasonable and necessary to provide the enrollee with adequate bilateral masticatory function. 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 denture have been met. Therefore, we decided that the Plan has to pre-approve a partial lower denture (D5226).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a specialist in Moh's surgery.
You asked the Plan to pre-approve the referral. You say that you have been referred to a dermatologist who does see routine dermatology problems. The Plan denied your request. The Plan says you have had a lump in your leg for over a month.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found your one month old skin lesion on the right calf requires a biopsy to establish a diagnosis. However, there is no Moh's consideration until then. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for a specialist in Moh's surgery
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 16, 2020.
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 Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.
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 laboratory services provided to the enrollee on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided on August 23, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network services provided on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 22, 2021.
You asked the Plan to pay for lab tests. You say that the Plan must provide coverage for this testing based on
Medicare regulations. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because you billed a test that was not performed, did not bill the applicable DEX Z-code required by
Medicare billing rules, and the order for this testing was not signed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory testing provided on February 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the retroperitoneal ultrasound provided on August 5, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 76770 was billed with code 93975. We find that CPT code 76770 may be eligible for payment when billed with this code pair. The claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the retroperitoneal ultrasound provided on August 5, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound and a CT scan provided on February 24, 2021, and March 4, 2021.
You asked the Plan to waive the copayments for an ultrasound and a CT scan. You say that there are conflicting reasons as to why you are being charged. You state that the provider is in-network and you should not be charged the $160 copayments. 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 $160 copayment for CT scans and ultrasounds. You received an ultrasound on February 24, 2021. Therefore, you are responsible to pay the $160 copayment.
You received a CT scan on March 4, 2021. Therefore, you are responsible to pay the $160 copayment. The total amount you owe is: $320. You have been asked to pay the total copayment amount of $320 for an ultrasound and a CT scan. An ultrasound and a CT scan fall 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 copayments for an ultrasound and a CT scan provided on February 24, 2021, and March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 77001) provided to the enrollee on September 3, 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 inclusive to another code.
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 the services is a column II code to column I code 36905. 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 (procedure code 77001) provided to the enrollee on September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fluoroscopic guidance for needle placement provided on May 24, 2021.
You asked the Plan to waive the copayment for the fluoroscopic guidance for needle placement. You say that you disagree with the increase in charges for this procedure. 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 $160 copayment for radiological diagnostic services. You have been asked to pay the allowed amount of $144.76, which is less than the $160 copayment for the fluoroscopic guidance for needle placement.
The fluoroscopic guidance for needle placement falls within the outpatient diagnostic tests and therapeutic
service 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 fluoroscopic
guidance for needle placement provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray services provided on October 2, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 71046 was billed with code 36558. We find that CPT code 71046 may be eligible for payment when billed with this code pair. The claim information provided does not show that code 71046 was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray services provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 must 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 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 out of network services provided to the enrollee on June 29, 2021.