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

We decided that the Plan does not have to waive the copayments for X-rays provided on May 11, 2021, and June 7, 2021.

You asked the Plan to waive the copayments for X-rays. You say that you had a spot that needed to be checked out and you do not understand the high charges. You state that you are low income and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for basic radiology provided in an outpatient hospital facility

You received an X-ray on May 11, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $81.99, which is less than the $95 copayment

You received an X-ray on June 7, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $81.99, which is less than the $95 copayment.

The total amount you owe is: $163.98.

You have been asked to pay the total amount of $163.98 for X-rays. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for X-rays provided on May 11, 2021, and June 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the prolonged evaluation and management service (99358) provided on
December 7, 2020.

You asked the Plan to pay for the prolonged evaluation and management service (99358). You say that the
physician provided medically necessary services that meet the professionally recognized standards of
healthcare. You say that the claim should be processed for payment at the maximum amount allowed. The Plan
denied your request. The Plan says that there are no modifiers that are allowed with this Procedure to Procedure
(PTP) code pair.

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. Specifically, the Plan has failed to forward any evidence that the column I code,
CPT code 99310 has been billed or paid. It is not appropriate to deny for bundling when there is no indication
that the column I code was paid. It is the burden of the Health Plan to substantiate their denial with evidence.
This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to
pay for the prolonged evaluation and management service (99358) provided on December 7, 2020.


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 coded 88361, 88312, 88305, and 88104 provided on March 17, 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 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. 

We find that CPT code 88361, 88312, 88305, and 88104 is not supported in the medical record. Specifically, these codes have a Professional Component/Technical Component (PCTC) indicator of 1. These services were billed with a place of service of 22, outpatient hospital. The professional interpretation was furnished in the same payment locality from where the technical component was furnished.

The Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier 26 by the interpreting physician. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 88104 provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee no longer meets criteria for acute rehabilitation and needs lower level of care of the SNF. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a new plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 12, 2021, by an
OON provider.

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the laboratory work provided on March 12, 2021, by an OON
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mouth splint.
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says there is no history of injury to the jaw.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a mouth splint
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (50650) provided on April 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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 50650
has a bundled relationship with code 50548 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 services (50650) provided on April 5, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
August 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 services provided by an out-of-network provider on August
21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission for a right total hip arthroplasty for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the planned procedure is not on the Inpatient Only list.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee did not require an inpatient stay for this surgery. Detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. Detailed documentation is not evident regarding peri-operative complications with previous surgeries. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient admission for a right total hip arthroplasty is not medically reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient admission for a right total hip arthroplasty for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Bio-Ice gel (A9900) provided December 29, 2019.
You asked the Plan to pay for the Bio-Ice gel. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the code billed is not eligible for payment under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code A9900 is not eligible for reimbursement according to Medicare rules. Specifically, the CPT code billed has a status indicator of "Y" which means it is not eligible for payment under Part B OPPS. This item must be billed to the Durable Medical Equipment Regional Carrier. Based on this information, we decided that Medicare rules for coverage of the Bio-Ice gel have not been met. Therefore, we decided that the Plan does not have to pay for the Bio-Ice gel (A9900) provided December 29, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device (33289).
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the CardioMEMS device. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found that given the severe symptoms of recurrent chronic heart failure (CHF) which appears very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalizations in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to support its use in selected appropriate clinical situations like this one. 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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device (33289).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium (75571).

You asked the Plan to pre-approve a CT of the heart. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested service is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT of the heart have not been met. Specifically, Medicare does not cover the requested service. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021, by an out-ofnetwork
provider.

You asked the Plan to pay for laboratory testing. You say that the enrollee has established care with the
provider at issue. The Plan denied your request. The Plan says rules for out-of-network care 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 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 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 laboratory testing provided on March 1, 2021, by an out-ofnetwork
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support that
LTACH care is medically necessary. The Plan denied your request. The Plan says LTACH care is not
medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and you do not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that you were admitted to the acute care hospital for an acute kidney injury, bacteremia, and a urinary tract infection. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Therefore, the requested LTACH services are not 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for your wheelchair ramp.

You asked the Plan to pre-approve the repairs. You say that you would like reconsideration because the member is at risk for falling and requires the ramp to safely enter their home. The Plan denied your request. The Plan says the ramp is considered a convenience item and not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 

This item is available to the general public and would be helpful even to those who are not sick or injured. This item is considered a convenience item and is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pre-approve repairs for your wheelchair ramp.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient admission for a right reverse total shoulder replacement surgery.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that the planned procedure is not on the Inpatient Only list.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does show that at the time of inpatient admission, the admitting physician reasonable expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. She has been approved for right total shoulder replacement. Detailed documentation is evident regarding significant risk factors that would place this enrollee at increased risk for peri-surgical complications. Therefore, the requested inpatient admission for right reverse total shoulder replacement surgery is medically reasonable and 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient admission for a right reverse total shoulder replacement surgery.

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.