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

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from February 23, 2021, to March 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 DRG was updated.

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. 

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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the medical record documentation was incomplete to reflect a persistently elevated serum creatinine level after adequate intravenous fluid resuscitation, abnormal urinalysis findings consistent with the condition, discontinuation of medications known to negatively impact renal function, or an increase in resource utilization consistent with the condition of acute tubular necrosis such as Nephrology consultation, urine chemistry studies, or renal imaging that would be consistent with this condition during the encounter. The review indicates that the records do not support that the correct DRG and diagnosis codes were used. 

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 inpatient hospital services provided to the enrollee from February 23, 2021, to March 3, 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 October 8, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you believe the panoramic x-ray was
necessary because the doctor needs to know what needs to be done on your teeth. You also say that you believe
this service should be covered. The Plan denied your request. The Plan says this service is not a covered
expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service
to verify benefits and provider eligibility.
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
panoramic x-ray (D0330) provided on October 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on July 8, 2021 by an out-of-network (OON) 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 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 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 testing services provided on July 8, 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 the therapeutic continuous glucose monitor equipment
provided on June 23, 2021.
You asked the Plan to pay for the medical equipment. You say that you would like this claim reprocessed based
on the submitted medical records. The Plan denied your request. The Plan says the criteria for coverage have
not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not relevant medical records which support medical necessity for the supplies provided in this
case. In this case, the medical records do not provide any evidence that the enrollee's provider ever discussed
the ordered equipment with the enrollee. The record shows that the Plan made several attempts to obtain the
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the
therapeutic continuous glucose monitor equipment provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on September 27, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you advised the provider who you were seeing for the first time not to provide procedures that would
not be covered by your insurance. You also say that the treating provider did not contact the plan in regards to
what services were and were not allowed, and they did not inquire about previous x-rays. The Plan denied your
request. The Plan says these services exceed the frequency limitations in your benefit 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, comprehensive oral evaluation
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure ever three plan
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of
intraoral x-rays (D0210) on March 18, 2021 and your comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210)
provided on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 20,
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 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 CPT code. In this case, we have confirmed that code 70544
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 20,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound services (procedure code 76705) provided to the enrollee on October 13, 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 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 CPT code. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. 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 ultrasound services (procedure code 76705) provided to the enrollee on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis with heel stabilizer rendered on April
7, 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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any durable medical equipment (DME) item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for the ankle foot orthosis with heel stabilizer rendered on April 7,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, fluorescence in-situ hybridization (FISH) testing, was requested solely for
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that
the Plan does not have to pay for the laboratory services rendered on August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound services received on September 5, 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 an appropriate modifier was not billed in this case.
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 76705
is a column II code to column I code 93976. 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 ultrasound services received on September 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spine surgery (22899) provided on June 3, 2021.

You asked the Plan to pay for the spine surgery (22899). You say that these services were provided out of medical necessity and the patient would not have received the appropriate medical attention if you did not provide this level of care. You say that the attached documentation should be reviewed, and the claim processed toward payment. The Plan denied your request. The Plan says procedure code 22899-62 is not supported by the medical records submitted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 22899 is unlisted procedure, spine.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the spine surgery (22899). Our reviewer says that the operative report does not mention an unlisted procedure being performed in this revision surgery and should be denied. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spine surgery (22899) have not been met. Therefore, we decided that the Plan does not have to pay for the spine surgery (22899) provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services, medical
examination provided on August 11, 2021.
You asked the Plan to waive the copayment for ophthalmological services, medical examination. The Plan
denied your request. The Plan says the services provided and the diagnoses listed on the claim are not
considered a routine visit; therefore, the $40 copay for vision services is applicable.
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 $40
copayment for Vision Care, Medicare-covered vision services.
You have been asked to pay a $40 copayment for ophthalmological services, medical examination. The
ophthalmological services, medical examination 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 ophthalmological services, medical examination provided on
August 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services and supplies
(95938, 95927, 95940, A4556 and A4215) provided on May 13, 2021.
You asked the Plan to pay for the intraoperative neuromonitoring services and supplies.. You say that you
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this
provider is not eligible to bill for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the intraoperative neuromonitoring services and supplies. have not been met. Specifically, the
record indicates that the member was in a facility with a valid POS code for the billed services. Additionally,
this provider is not eligible to bill for the services rendered. Payment for these services and supplies is included
into the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that
the Plan does not have to pay for the intraoperative neuromonitoring services and supplies (95938, 95927,
95940, A4556 and A4215) provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) provided on April 20, 2021.  You asked the Plan to pay for the CGM (K0554). 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.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (86671, 82164) provided on July 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you did not understand how the Plan worked. The Plan denied your request. The Plan says these services were not authorized.  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 (86671, 82164) provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (86200, 86255, 86235, 86225, 86431) provided on July 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you were not aware that you had to get all tests done through the Plan, nor that you needed any sort of authorization before doing any test or medical procedures outside of the Plan. You also say that the providers did not inform you that the testing would be done in a different laboratory than the Plan requires, nor did they try to contact the Plan for any authorization. The Plan denied your request. The Plan says these services were not authorized by the Plan, and this is a non-contracted provider who performed services to the member without prior authorization from the Plan.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (86200, 86255, 86235, 86225, 86431) provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (procedure code 00145) provided to the enrollee on July 12, 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 a surgical code that appropriately crosswalks to the anesthesia services must be reported to support the anesthesia 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, the CPT Code Manual definition of code 00145 is "Anesthesia for procedures on eye; vitreoretinal surgery."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, the anesthesiologist billed CPT 00145 AA QS (modifier AA is performed personally by the anesthesiologist; modifier QS is for monitored anesthesia care), with a base value of 6. The correct CPT code is 00142, with a base value of 4. The records do not support the anesthesia billing code of CPT 00145 for the operative procedure performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (procedure code 00145) provided to the enrollee on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for intraoral x-rays (D0220 and D0230) provided by a participating provider on September 30, 2021.  You asked the Plan to pay for intraoral x-rays. You say that you feel like the Plan should pay for this. The Plan denied your request. The Plan says the x-rays that were provided are not covered dental benefits.  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 intraoral x-rays (D0220 and D0230) provided by a participating provider on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (86003, 86038, 86140, 86146, 86147, 86160) provided on July 8, 2021, by an out-of-network (OON) provider  You asked the Plan to pay for laboratory services. You say that you were not aware that you had to get all tests done through the Plan, nor that you needed any sort of authorization before doing any test or medical procedures outside of the Plan. You also say that the providers did not inform you that the testing would be done in a different laboratory than the Plan requires, nor did they try to contact the Plan for any authorization. The Plan denied your request. The Plan says these services were not authorized by the Plan, and this is a non-contracted provider who performed services to the member without prior authorization from the Plan.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (86003, 86038, 86140, 86146, 86147, 86160) provided on July 8, 2021, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on May 7, 2021.  You asked the Plan to pay for code 99153. 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 review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on May 7, 2021.