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

 We decided that the Plan does not have to pay for the emergency department visit (99285) provided on August 21, 2021.  You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says this is not a covered diagnosis.  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 specific dental services when rendered by a dentist.   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 emergency department visit. Our reviewer says that the member presented at the emergency department with a history of dental pain. The examination revealed the pain had been present for several days, that biting on a stick elicited pain, and that there was no obvious abscess.  The clinical impression section of the chart noted: Pain, Dental; Dental Caries; Jaw pain Our physician reviewer found that it is clear from the record that the services rendered of examination and providing of prescriptions for dental pain that the primary focus of the visit was dental in nature.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided on August 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a sacral nerve stimulator.  

You asked the Plan to pre-approve a sacral nerve stimulator. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says the coverage criteria have not been met.  

The Plan follows Medicare rules. Medicare rules say that patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the three indications listed in the Medicare rules section are excluded.  

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 sacral nerve stimulator. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found you are an 89-year-old female with urinary retention, bladder stones, recurrent urinary tract infection, nocturia, urgency, urinary incontinence, atrophy of vulva, atonic bladder, and diabetes. In this case, there is no medical documentation that the enrollee's urinary retention is not being caused by diabetic peripheral nerve involvement (diabetic cystopathy). Sacral nerve stimulator trial is not covered if peripheral nerve involvement (diabetic cystopathy) is present.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sacral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider from April 13, 2021, through May 13, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider from  April 13, 2021, through  May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Intracept spinal procedure.  

You asked the Plan to pre-approve Intracept spinal procedure. 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 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 Intracept spinal procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spondylosis without myelopathy or radiculopathy, lumbar region and low back pain medical condition. The Intracept procedure remains experimental. More research is needed to show safety and efficacy. 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 Intracept spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept spinal procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 20, 2021, to February 21, 2021.  

You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this stay is correct, because inpatient level of care was not needed and this stay could have been provided at the observation level instead.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found due to the enrollee having acute coronary syndrome (ACS) rules out during the initial workup and no other acute condition identified requiring prolonged inpatient care and as the enrollee was hemodynamically stable, continued workup could have been completed under observation care. The notes do not suggest a need for the enrollee to receive hospital care that would likely span at least 2 midnights.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided February 20, 2021, to February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a consultation, diagnostic service provided by a dentist or physician other than a requesting dentist or physician (D9310) provided on October 14, 2021.  You asked the Plan to pay for a consultation, diagnostic service. You say that you were unaware that this was not a covered benefit. The Plan denied your request. The Plan says the service requested is not a covered benefit with your 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 a consultation, diagnostic service provided by a dentist or physician other than a requesting dentist or physician (D9310) provided on October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81479, 81401, 81225, 81227, 81226, 81231, 81328, and 81335) provided on May 12, 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 (81479, 81401, 81225, 81227, 81226, 81231, 81328, and 81335) provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (72192) provided September 14, 2021.  

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and is not separately payable.  

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 72192 has a bundled relationship with code 74177.   

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 radiology services (72192) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 00528 provided on May 20, 2021.  You asked the Plan to pay for the anesthesia services. 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 00528 is anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing 1 lung ventilation.    We find that CPT code 00528 is not supported in the medical record. Specifically, the documentation submitted did not include medical records. This means this code is not supported by the documentation provided. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00528 provided on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on May 1 to May 29, 2020.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for psychotherapy services was not filed until June 3, 2021. This means that more than one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on May 1 to May 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an upper gastrointestinal endoscopy (43248) provided on July 21, 2021, at a hospital outpatient facility.  You asked the Plan to waive the copayment for an upper gastrointestinal endoscopy. You say that you are on a fixed income and are asking the Plan to lower the payment. 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 $375 copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility.    You have been asked to pay a $375 copayment for an upper gastrointestinal endoscopy. An upper gastrointestinal endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 upper gastrointestinal endoscopy (43248) provided on July 21, 2021, at a hospital outpatient facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on August 29, 2020, through September 5, 2020.

You asked the Plan to waive the copayment for the inpatient hospital care. 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 $275 copayment each day one through six for inpatient hospital care. 

You have been asked to pay a $275 copayment each day one through six for the inpatient hospital care. This service falls within the inpatient hospital 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 the inpatient hospital care provided on August 29, 2020, through September 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for vision care provided on October 5, 2021.  You asked the Plan to waive the copayment for vision care. You say that you were told that this was a routine service and you would not owe a copayment. 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 $20 copayment for an eye exam to diagnose and treat diseases and conditions of the eye and a $0 copayment for one routine eye exam per year for vision care.   The medical records show that you received vision care that went beyond routine care on October 5, 2021. Therefore, you are responsible to pay the $20 copayment.   You have been asked to pay a $20 copayment for vision care. Vision care falls within the vision 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 vision care provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency medical services provided May 30, 2021.  

You asked the Plan to pay for the emergency medical services. You say that this was an emergency, and these services should be covered. The Plan denied your request. The Plan says services received at a Veterans Affairs hospital are normally not covered unless necessary documentation is submitted.  

The Plan must follow Medicare rules. Medicare rules say that appropriate documentation must be provided to determine whether payment is due and the amount of payment.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. In addition, proof of payment that is necessary for reimbursement requests was also not approved. Without this documentation, the Plan cannot determine if payment should be made based on the difference between the charged amount and the Plan's cost sharing. Based on this information, we decided that Medicare rules for coverage of the emergency medical services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency medical services provided May 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided August 18, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. 

We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798 are not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (32, rehab facility). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a neurostimulator placement (64555).  

You asked the Plan to pre-approve the neurostimulator placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and is non-covered.  

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 neurostimulator placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental. More research is needed to show safety and efficacy.         

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 neurostimulator placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator placement (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99202) and skin lesion trim (11055) provided on May 23, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the office visit and skin lesion trim. You say that you would like reconsideration because there was a misunderstanding and services were rendered assuming authorization had already been obtained. The Plan denied your request. The Plan says the member's health insurance plan requires services to be performed by a contracted provider.  

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 office visit (99202) and skin lesion trim (11055) provided on May 23, 2021 by an out-of-network (OON) provider.