Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a crown upgrade received on August 13, 2021.  You asked the Plan to pay for the dental services. You say that the original dentist should cover the cost for the new crown. The Plan denied your request. The Plan says you agreed to a material upgrade for an additional charge.  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 replacement crowns, but the enrollee is responsible for any material upgrades.  The file shows that you are receiving reimbursement for the charges paid for the original crown. The new crown was covered as the original was deemed to be unsatisfactory, but there are additional charges as you received a crown that is considered materially upgraded. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for a crown upgrade received on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a diabetic shoe (A5500) and insert (A5512), to be provided by an OON provider.  You asked the Plan to pre-approve a diabetic shoe and insert. You say that the items are medically necessary. The Plan denied your request. The Plan says there are in-network providers that could provide these items.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.     The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a diabetic shoe (A5500) and insert (A5512), to be provided by an OON provider.
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 July 11, 2020, to July 19, 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 the DRG was updated in this case.  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 . 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 review has determined that the documentation within the medical record was incomplete regarding the diagnosis of hypoxemic respiratory failure. The documentation consistently records no acute distress with unlabored respirations at rest and no accessory muscle use. Supplemental oxygen via nasal cannula was utilized during treatment of pneumonia without the need for ventilatory assistance or an increased level of care or additional monitoring. Provider documentation did not reflect the patient's baseline paO2 levels in the setting of chronic pulmonary disease and venous or arterial blood gases were not repeated after initial gas in the ED. The documentation evidence was incomplete in the records available for review to substantiate a diagnosis of respiratory failure. The records did not support that the correct DRG and diagnosis codes were used in this case.   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 July 11, 2020, to July 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric admission.  You asked the Plan to pre-approve inpatient psychiatric admission. 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 inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 22, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services (D1999) received on July 12, 2021.  You asked the Plan to pay for the services. You say that payment should be reconsidered. The Plan denied your request. The Plan says this is not a covered 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 dental services (D1999) received on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services provided by a chiropractor on June 7, 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 these services are not covered when provided by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for acupuncture services provided by a chiropractor on June 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 76700) provided to the enrollee on August 9, 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 76700 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 imaging services (procedure code 76700) provided to the enrollee on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the retainer crown (D6740) and pontic (D6245).  You asked the Plan to pre-approve the crown and pontic. You say that the service is medically necessary. The Plan denied your request. The Plan says the services are not covered.    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. Specifically, the services are not listed in the Plan's benefit chart. This means they are not covered services. Therefore, we decided that the Plan does not have to pre-approve the retainer crown (D6740) and pontic (D6245).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head/brain to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a CT scan of the head/brain to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head/brain to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on April 6, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that the transportation was considered emergent, and the enrollee should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for ambulance services.     The enrollee has been asked to pay the allowed amount of $198.38, which is less than the $250 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the therapeutic procedure (97110), and physical therapy evaluation (97162), to be provided by an OON provider.  You asked the Plan to pre-approve the therapeutic procedure and physical therapy evaluation. You say that you would rather go to the out-of-network facility. The Plan denied your request. The Plan says there are in-network providers that can provide these services. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the therapeutic procedure (97110), and physical therapy evaluation (97162), to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for surgical removal of a central venous catheter provided on June 29, 2021.  You asked the Plan to waive the copayment for outpatient surgery. You say that you feel that this visit was not a surgical procedure. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  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 $325 copayment for outpatient surgery at an outpatient hospital. This service is considered to be a surgical service; therefore, the outpatient surgery copayment applies to this claim.  You have been asked to pay $325 copayment for outpatient surgery. Outpatient surgery 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 surgical removal of a central venous catheter provided on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity is not established.  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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in a home exercise program and his functional level does not require the professional skills of a therapist. The requested services are not part of a maintenance program.  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 home health services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan.  You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this MRI is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee has low back pain when sleeping which causes insomnia. The record indicates that she does not have pain with activity. The record does not indicate recent trauma and the neurological examination is normal. The record does not indicate a trial of conservative therapy. Therefore, the requested MRI is not medically necessary for the diagnosis and treatment of the enrollee's condition at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the pelvic ultrasound you had on March 24, 2021.  You asked the Plan to waive the copayment for the pelvic ultrasound. You say that this service is a follow-up visit after surgery and should be included as part of the original procedure. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($49.30) is less than your copayment obligation, you are responsible for the full allowed 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 an $80 copayment for radiological diagnostic services.   Medicare rules state that when you have a surgery, certain services are considered part of the surgery itself and not separately payable.  This is called the global surgical package.  However, diagnostic radiology services (such as the ultrasound you had), are not considered part of the global surgical package, so separate cost sharing can apply. You have been asked to pay an $80 copayment for the pelvic ultrasound. 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 pelvic ultrasound you had on March 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee 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 primary procedure code 76856 and 93976 and appealed bundled code 93976 and 76705 were billed with modifier 26. This modifier is not included in the list of NCCI allowed modifiers. Therefore, codes 93976 and 76705 was not billed with the required modifier and is considered bundled into the previous payment of 76856.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an error with the association of the codes billed and an incorrect modifier. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acute inpatient level of care.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  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 pre-approve these services. Our reviewer says that the criteria for coverage of inpatient care are not met. Our physician reviewer found the enrollee is approved for a procedure that is not on the inpatient-only list and is not expected to require two midnights of the inpatient level care. There is no documentation of uncontrolled co-morbidities pre-procedure to warrant authorization of a prolonged (i.e. two midnight) stay. The inpatient admission is not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the acute inpatient level of care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion device.  You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is 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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.