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

We decided that the Plan does not have to pay for the inpatient hospital services rendered on March 21, 2021,
to March 23, 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 submitted records do not support the billing of DRG 872 and diagnosis code A41.9.
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 872 (septicemia or severe sepsis without mv
>96 hours without mcc) and diagnosis code A41.9 (unspecified sepsis). 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 872 and diagnosis code A41.9. Our physician reviewer found the enrollee presented to the
hospital with a white blood cell count of 6, platelets of 345, and lactic acid at 1.8. The overall infection process
was not found after workup and symptoms were thought to have been from recent Coronavirus vaccination and
poor oral intake, as she responded to intravenous fluids. The criteria for SIRS or sepsis are not met; therefore,
the billing of DRG 872 and diagnosis code A41.9 are not supported.
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 on March 21, 2021, to March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing coded 81479 provided on January 6, 2021.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the genetic testing is not supported in the medical record. Specifically, the documentation does not
support that the services were ordered by the enrollee's treating physician. Based on this information, we
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that
the Plan does not have to pay for the genetic testing coded 81479 provided on January 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. The Plan denied your request. The Plan says the documentation received shows progress toward the enrollee's goals. The Plan also says that teaching and education should have occurred in the previous visits.
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 visits. Our reviewer says that the requested skilled nursing services are not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve three skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 8, 2020.
You asked the Plan to pay for the services provided. You say that physician's send specimens for testing. The
Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The claim provided lists the place of service as an independent laboratory.
The records provided do not indicate the specimen at issue was obtained at an independent laboratory. 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 the drug testing services provided on December 8, 2020.
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 did not know this type of x-ray was not covered and you are not sure why you had this x-ray instead of a covered one. The Plan denied your request. The Plan says panoramic x-rays are not covered by your dental benefit.
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 April 28, 2021.
Your complaint about non-covered services and potential misinformation from a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay provided from November 27, 2018, through June 27, 2019.
You asked the Plan to pay for the inpatient stay. You say that the inpatient stay was medically necessary. The Plan denied your request. The Plan says the ongoing inpatient hospital stay provided from November 27, 2018, through June 27, 2019 was not medically necessary as the patient was custodial and required placement/disposition rather than acute medical care.
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 pay for the inpatient stay. Our reviewer says that the ongoing hospital stay provided from November 27, 2018, through June 27, 2019 was not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 85-year-old female who was admitted and treated in the hospital for a urinary tract infection and syncope due to orthostatic hypotension. Some cardiac medications were held, and she was treated with antibiotics. Her complete blood count was normalizing, and the enrollee was responding to treatment and was stable by November 27, 2018. No other acute condition was noted. She was homeless and placement was challenging. The ongoing inpatient stay from November 27, 2018, through June 27, 2019 was not medically reasonable and necessary as the enrollee was custodial and required placement/disposition rather than acute medical 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 the inpatient stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient stay provided from November 27, 2018, through June 27, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70551) provided May 15, 2021.
You asked the Plan to pay for the MRI of the brain. You say that this claim was billed correctly. The Plan denied your request. The Plan says the claim has been billed with a place of service inconsistent with hospital inpatient status.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that when a patient is inpatient, the services must be billed with POS code 21. We find that CPT code 70551 is not supported in the medical record. In this case, the record demonstrates that the enrollee was inpatient for the services in question and these services were billed with POS code 22 instead of the correct POS code 21. Based on this information, we decided that Medicare rules for coverage of the MRI of the brain have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70551) provided May 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 18,
2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.
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 subsequent nursing facility care provided on
August 18, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from February 12, 2021, to February 23, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you were advised by the Plan that a coronavirus-related hospitalization was 100% covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $390 copayment for each day for days 1 to 4 each time you are admitted and $0 copayment for additional Medicare-covered days, up to 90 days.
You have been asked to pay a $390 copayment for each day, 1 to 4 for the inpatient hospital admission. ($390 x 4 = $1,560). The inpatient hospital admission falls within the "Inpatient Mental Health Care" benefit category. The record shows copayments, coinsurance, and deductibles for inpatient hospital services are not waived. 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 admission provided from February 12, 2021, to February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during arthroplasty services.
You asked the Plan to pay for the assistant surgeon services during arthroplasty services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed
are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correct ly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement,
extensive.
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 assistant surgeon services during arthroplasty services.
Our reviewer says that the documentation does not support the billing of 28923-AS. Our reviewer found the operative report does not include detailed documentation of extensive debridement to include 3 or more discrete structures in the shoulder. Therefore, extensive debridement cannot be confirmed as 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 assistant surgeon services during arthroplasty services have not been met.
Therefore, we decided that the Plan does not have to pay for the assistant surgeon services during arthroplasty services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided on May 9, 2021
to May 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says authorization
was not obtained prior to the services rendered.
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 skilled nursing facility services provided on May 9, 2021 to May 18, 2021 by
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 13, 2021.
You asked the Plan to pay for the drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug
testing coded G0483 provided on January 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy evaluation provided by an
occupational therapist on February 22, 2021.
You asked the Plan to pay for the occupational therapy evaluation. The Plan denied your request. The Plan says
the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services
incident to a physician/non-physician practitioner's service must meet all incident requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the occupational therapy evaluation have not been met. Specifically, the billing provider is a nurse
practitioner. As such, OT services cannot be paid incident to this provider's professional services. Therefore,
we decided that the Plan does not have to pay for the occupational therapy evaluation provided by an
occupational therapist on February 22, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on March 26, 2021.
You asked the Plan to pay for the non-emergency ambulance transport and ground mileage. You say that these services were medically necessary. The Plan denied your request. The Plan says ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is considered part of the inpatient admission, and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider.
The record also shows that the enrollee was moved to another provider while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on March 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement coded 76942
provided on January 26, 2021.
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 76942
for the ultrasonic guidance for needle placement service has a bundled relationship with code 76937 and cannot
be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic
guidance for needle placement coded 76942 provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the glasses, lenses and frames purchased on May 18, 2021.
You asked the Plan to pay for the glasses, lenses and frames. You say that you don't know how the allowance has been exhausted when you haven't used the benefit in two years. You say that you haven't purchased glasses since April 2019 and are entitled to this allowance. The Plan denied your request. The Plan says the claim processed correctly.
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 $250 toward the purchase of eyewear every calendar year. We looked at the file and the Plan's rules. The Plan paid $250 toward the glasses, lenses and frames purchased on May 18, 2021. Based on this information, we decided that the Plan's rules for additional coverage of the glasses, lenses and frames have not been met. Therefore, we decided that the Plan does not have to pay more for the glasses, lenses and frames purchased on May 18, 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 May 6, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you went to a new dentist and had a lot of x-rays taken. You also say that they never asked you if you wanted the x-rays, nor did they offer to clean your teeth. The Plan denied your request. The Plan says this benefit has been exhausted.
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, full mouth and/or panoramic x-rays share a frequency limit of two procedure codes every three years. The record shows that you received a panoramic x-ray (D0330) on August 21, 2018 and a complete series of intraoral x-rays (D0210) on May 6, 2021 and your full mouth and/or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on May 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical care provided to the enrollee on April 25, 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 due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for medical care provided to the enrollee on April 25, 2021.