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

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 16, 
2021.

You asked the Plan to pa
y for the CT scan. The Plan denied your request. The Plan says an appropriate 
modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.

The file shows that CPT code 70491 was billed along with code 70498. We find that CPT code 70491 may be 
eligible for payment when billed with this code pair. However, the claim information does not show that code 
70491 was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomography (CT) scan provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered on March 13, 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 procedure code 99497 is not supported.

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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate.

We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of 
a discussion between the provider and patient regarding eventual end-of-life decisions. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the advance care planning rendered on March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 12, 2021, by an out-ofnetwork (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service rendered does not require 
preauthorization. The Plan denied your request. The Plan says the service rendered does not require 
preauthorization.

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. 
Therefore, we decided that the Plan does not have to pay for the drug testing provided on May 12, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the external ocular photography service provided on July 16, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the external ocular photography service. You say that it is not possible to request authorization before the service was rendered. 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. Therefore, we decided that the Plan does not have to pay for the external ocular photography service provided on July 16, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan has to pay for ambulance services (A0429 and A0425) provided on March 8, 2021.

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this 
claim denied in error. The Plan denied your request. The Plan says that they do not pay for services which are 
payable by an automobile insurance plan.

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 initially denied this service indicating that the member's 
primary insurance is through another carrier. The Plan has not forwarded any evidence that the member has 
additional coverage. The record also does not show that the Plan coordinated their benefits with the primary 
insurers by sending the bill directly to the primary insurer for payment, directing the provider to send the bill to 
the primary insurer or paying for the services and submitting a bill for reimbursement to the primary insurer. It 
is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not 
been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for ambulance 
services (A0429 and A0425) provided on March 8, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON lab services. You say that you provided these services in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 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 lab services provided on July 29, 2021, 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 care provided on February 2, 2021, through February 11, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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). Your contract with the Plan clearly says that you must pay a $325 copayment each day one through 6 for inpatient hospital care. 

You have been asked to pay a $325 copayment each day one through 6 for the inpatient hospital care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on February 2, 2021, through February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional
intraoral periapical x-ray (D0230), cone beach computed tomography (CT) capture and interpretation (D0364),
pulp vitality tests (D0460), preventive procedure (D1999), core buildup, including any pins when required
(D2950), endodontic therapy (D3330), and consultation (D9310) provided on July 12, 2021.
You asked the Plan to pay for the dental services. You say that you are to go to the dentist that is not innetwork
and you do not have out-of-network coverage. The Plan denied your request. The Plan says your 2021
benefit maximum had been met.
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 Plan offers a maximum plan
benefit coverage amount of $1,000 per year, which applies to all supplemental (i.e., routine) dental services.
The contract says that you are responsible for any cost above the $1,000 maximum. The record shows that you
met the annual maximum benefit on October 5, 2021, and your annual maximum benefit for 2021 has been
exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray
(D0220), additional intraoral periapical x-ray (D0230), cone beach computed tomography (CT) capture and
interpretation (D0364), pulp vitality tests (D0460), preventive procedure (D1999), core buildup, including any
pins when required (D2950), endodontic therapy (D3330), and consultation (D9310) provided on July 12,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 17, 2021.

You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496.

This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan of the soft tissue of the neck (70491) provided on September 3, 2021, by an out-of-network provider.

You asked the Plan to pay for a CT scan of the soft tissue of the neck. You say that the service at issue was a medical necessity for the enrollee. 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 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 a CT scan of the soft tissue of the neck (70491) provided on September 3, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 16, 2021.  You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 23. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 16, 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 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 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. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met 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 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on May 20, 2021.  

You asked the Plan to pay for the emergency department visit. 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 99285 for the emergency department visit is a column II code to column I code 99291. 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 the emergency department visit coded 99285 provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision services provided on May 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the vision services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.  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 vision services provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy services coded 52001 provided on May 14, 2021.

You asked the Plan to pay for the cystourethroscopy 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 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 52001 for the cystourethroscopy services is a column II code to column I code 52214. 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 the cystourethroscopy services coded 52001 provided on May 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of a skilled nursing facility (SNF) admission for the enrollee.

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 issues appear to be essentially stabilized.

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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is walking household distances and tending to activities of daily living with minimal supervision. 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 are custodial and, as a practical matter, can be provided at a lower level of care, such as home health services, assisted living, or long term 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services provided on June 4, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date
of service. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that codes 75726 and 75774 were billed with a -59 modifier. The medical records provided do
not show that the service billed with the -59 modifier is a distinct procedural service. Based on this
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the
Plan does not have to pay for the angiography services provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services coded 62324 provided on February 19, 2021.  

You asked the Plan to pay for the injection 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 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 62324 for the injection services is a column II code to column I code 00794. 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 the injection services coded 62324 provided on February 19, 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee would benefit from skilled therapy services in an inpatient setting with medical monitoring.

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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 provided on June 4, 2021.
You asked the Plan to pay for the office visit. 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 99214 for the office visit is a column II code to column I code 20552.
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 the office visit coded 99214 provided on June 4, 2021.