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

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 29, 2021, through May 5, 2021.
You asked the Plan to waive the copayment for inpatient hospital services. You say that the services should be covered. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment per admission for inpatient hospital care. The enrollee has been asked to pay a $325 copayment per admission for inpatient hospital services. The services at issue fall within the inpatient hospital care 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 inpatient hospital services provided from April 29, 2021, through May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services (99070) provided on February 15, 2021, through March 21, 2021.
You asked the Plan to pay for the home health aide services. You say that you would like reconsideration because these services are a Medicare covered benefit. The Plan denied your request. The Plan says custodial care is not a covered benefit.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at your request, the file and Medicare rules. Based on this information we decided that Medicare
coverage criteria for the home health aide services have not been met. Specifically, the record does not show that there is an ongoing order for skilled nursing or skilled therapy. Additionally, the record indicates that these services were not rendered by a home health agency. Therefore, we decided that the Plan does not have to pay for the home health aide services (99070) provided on February 15, 2021, through March 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
You asked the Plan to pre-approve the procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the procedure is experimental and is not 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 procedure. 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 investigational at this time. More research is needed to show safety and efficacy of interspinous devices. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Yupelri.

You asked the Plan to pre-approve Yupelri. You say that the requested Yupelri is medically necessary. The Plan denied your request. The Plan says that the requested Yupelri is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Yupelri. Our reviewer says that the requested Yupelri is medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is documentation that the Yupelri is medically reasonable and necessary for the enrollee. Yupelri is approved by the Food and Drug Administration for treatment of chronic obstructive pulmonary disease; the enrollee has a documented diagnosis of chronic obstructive pulmonary disease in the provided records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yupelri have been met. Therefore, we decided that the Plan has to pre-approve Yupelri.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2020.
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. Medicare says that, for edits with a modifier indicator of 0, the Column 2 code is not payable. In this case, the provider submitted a claim for codes 81355 and 81227. Codes 81355 and 81227 are column II codes with a modifier indicator of 0 when billed with column I code 0030U. Codes 81355 and 81227 are not separately payable. The rules also say if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. In this case, the medical records provided do not confirm that the labs (81240, 81291, 81241, 81335, 81230, 81225, 81226, and 81408) were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided December 24, 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 billed services.
The Plan must follow Medicare rules. Medicare rules say that that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The documentation did not include an order from the treating physician. 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 (81479) provided December 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the rental of a CPAP device (E0601) on May 11, 2020, to March 11, 2021.

You asked the Plan to pay for a CPAP device. You say that you should not be liable for the rental charges in question. The Plan denied your request. The Plan says rules for payment for a CPAP device have not been met.

The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Specifically, compliance reports in the case record do not document use of a CPAP device for greater than or equal to 70% of nights. Therefore, we decided that the Plan does not have to pay for the rental of a CPAP device (E0601) on May 11, 2020, to March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected represented by code 0202U provided on October 27, 2020.

You asked the Plan to pay for code 0202U. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 0202U is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Medicare says that code 0202U is not covered. Therefore, we decided that the Plan does not have to pay for the infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected represented by code 0202U provided on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from February 15, 2021, to February 19, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that these services were medically necessary, and you cannot afford this bill. The Plan denied your request. The Plan says these services have been covered and your copayment has been applied correctly in accordance with your contract and cost sharing guide.
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 $250 copayment for each of the first three days of inpatient hospital care. There is a $0 copayment for additional days.
You have been asked to pay a $750 copayment for four days of inpatient care. 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 and services provided from February 15, 2021, to February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for progressive lenses (V2781) and anti-reflective coating (V2750) provided on April 19, 2021.
You asked the Plan to reimburse you for progressive lenses and anti-reflective coating. You say that your summary of benefits states that you would be reimbursed $125 every year for eyeglasses. You also say the reimbursement went to the provider and not you. The Plan denied your request. The Plan says exhausted your benefit, and you are responsible for the remaining balance.
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 contract says that you receive a $125 benefit allowance towards the purchase of eyewear every year. You are responsible for any amount above the eyewear coverage limit. We looked at the file and the Plan's rules. You purchased eyeglasses, lenses and anti-reflective coating. The records show that the total amount billed by the provider was $448.95. The provider discounted $230.42 which included your benefit allowance of $125, leaving a balance of $218.53. The records also show that you exhausted your $125 maximum allowed benefit and are responsible for the remaining balance of $218.53. Based on this information, we decided that the Plan's rules for coverage of progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to reimburse you for progressive lenses (V2781) and anti-reflective coating (V2750) provided on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on April 2, 2021.
You asked the Plan to pay for physical therapy services. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. 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 the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on April 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on March 1, 2021.
You asked the Plan to pay for psychotherapy, 30 minutes with patient (90832). You say that your physician provided medically necessary services to the member in good faith. The Plan denied your request. The Plan says there was no documented contact with the attending /primary care physician.
The Plan must follow Medicare rules. Medicare rules say that there must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record. We looked at the file and Medicare rules. There is no documentation of consent/declination or consultation with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy, 30 minutes with patient (90832) have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from December 22, 2020, through January 5, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show what kind of precautions were taken prior to treating the patient and the code should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is bundled into payment with the other services.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from December 22, 2020, through January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) on tooth #29 provided on May 13, 2021.

You asked the Plan to pay for the crown. You say that your crown broke off at the gum line and took the post with it. You also say that your dentist had to provide a new crown because your previous crown was not repairable. The Plan denied your request. The Plan says you are only allowed a dental crown once per tooth in a five-year period.

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, a crown, veneer, or onlay on the same tooth is covered once in a five-year period from the seat date. The record shows that you received a crown (D2740) on tooth #29 on June 4, 2018, and your crown benefit for tooth #29 has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #29 provided on May 13, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on March 15, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the claim is missing valid current procedural terminology (CPT) codes.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that there is insufficient documentation in the case file to support the Plan's denial. There are no immediate issues with the claim submitted. The place of service and CPT codes appears appropriate. There is no documentation that substantiates the Plan's denial. Therefore, we decided that the Plan has to pay for the laboratory services provided on March 15, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of tooth roots (D7250) and implant (D6010) provided on January 25, 2021.
You asked the Plan to pay for the dental services. You say that it was financially better for you to have these services out of network than in network. You say that the cost for the services from an in network provider would have been a lot more than they were from the out of network provider. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services you receive out of network are not covered. The Plan also says that there are in network dentists that could have provided these services.
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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of tooth roots (D7250) and implant (D6010) provided on January 25, 2021.