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

We decided that the Plan does not have to pay for laboratory services (procedure code 88305) 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 the provider did not bill as required by Medicare coding regulations.
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 88305 is not supported in the medical record. Specifically, the enrollee was outpatient on the denied date of service, and should have been reported with a modifier. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure code 88305) provided to the enrollee on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of inpatient psychiatric care from February 25, 2022, forward.
You asked the Plan to pay for continued inpatient psychiatric care. You say that additional days in this setting are medically necessary. The Plan denied your request. The Plan says as of February 25, 2022, the enrollee no longer meets the criteria for inpatient psychiatric care and can be treated in a less restrictive setting.
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 pay for continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric services at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on February 1, 2022, with Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon a review of the records provided, it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and was without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 25, 2022, forward, and could have been treated in a lesser restrictive setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for continuation of inpatient psychiatric care from February 25, 2022, forward.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the stem cell harvest (38206) and stem cell transplant (38241).
You asked the Plan to pre-approve the stem cell harvest (38206) and stem cell transplant (38241). You say that
the member will not use any inhaled form of marijuana and will be followed up on his use of edible cannabis.
You say that the approval of the stem cell transplant should be reconsidered. The Plan denied your request. The
Plan says that unmanaged or inadequately managed significant marijuana use in the context of non-compliance
in a post-transplant plan of care does not meet the minimum standards for quality of care.
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 stem cell harvest (38206) and stem
cell transplant (38241). Our reviewer says that the requested items/services are considered medically
reasonable and necessary in this case. Our physician reviewer found the patient has met with social work and
agreed to comply with edible cannabis use, which the oncologist has agreed to monitor during transplant period
that has been established. The member has met the criteria for the transplant regarding his cannabis use.
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 stem cell harvest (38206) and stem cell transplant (38241) have been met.
Therefore, we decided that the Plan has to pre-approve the stem cell harvest (38206) and stem cell transplant
(38241).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
You asked the Plan to pre-approve ablation services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that fluid jet system treatment will be considered not reasonable and necessary when the enrollee has known or suspected prostate cancer We looked at the file and Medicare rules. In this case, the documentation provides evidence that the enrollee has recently diagnosed prostate cancer. The requested waterjet ablation of the prostate will be considered not medically reasonable and necessary for recently diagnosed prostate cancer. Based on this information, we decided that Medicare rules for coverage of ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2391), endodontic therapy (D3330), and adjunctive procedure (D9999) provided on May 19, 2021.
You asked the Plan to pay for the resin-based composite, endodontic therapy, and adjunctive procedure. You say that this treating provider was listed as a Medicare provider at the time of these services. You also say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says you received conflicting and incorrect information during your calls with the Plan. The Plan also says that this claim has been reprocessed to show that you have already received the maximum amount of coverage allowed for this type of service.
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 $1,000 annual dental benefit maximum. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on December 6, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2391), endodontic therapy (D3330), and adjunctive procedure (D9999) provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).

You asked the Plan to pre-approve the feature. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.

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. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
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 13, 2021, to July 16, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. 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 DRG 077 (HYPERTENSIVE ENCEPHALOPATHY WITH MCC). 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 while the enrollee presentation warranted consideration of metabolic encephalopathy there was no documentation of neurological exams consistent with a diagnosis of metabolic encephalopathy. There was no evidence of a diagnostic work up for metabolic encephalopathy to validate this diagnosis. The submitted physician progress notes did not indicate any testing lab or radiology testing was performed specifically validate metabolic encephalopathy. The review has determined that the submitted medical records did not indicate treatment, testing, or cause of metabolic encephalopathy.
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 13, 2021, to July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the primary care visit you had on September 16, 2021.

You asked the Plan to waive the coinsurance for the primary care visit. You say that you have both Medicare and Medicaid. The Plan denied your request. The Plan says you did not present your Medicaid card when you went to the doctor. Your Medicaid benefits pick up your cost sharing.

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 Michigan Medicaid program covers your cost sharing for Medicare services. Your Plan claims will process with Original Medicare benefits. If your Medicaid picks up the difference, you will owe $0 cost share that is indicated in your benefits chart.

You have been asked to pay the applicable Original Medicare coinsurance of 20% for the primary care visit. According to your contract, your Medicaid is responsible for paying your cost sharing. You did not present your Medicaid card to your doctor. You will need to provide your Medicaid information to your doctor so that they can bill Medicaid for the coinsurance. Your contract says that Original Medicare cost sharing (in this case, 20% coinsurance) applies and will show on your claims. Therefore, we decided that the Plan does not have to waive the coinsurance for the primary care visit you had on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray (D0220), additional periapical x-ray (D0230), scaling and root planing (D4342), and localized delivery of antimicrobial agents (D4381) provided from September 28, 2021, to October 15, 2021.

You asked the Plan to pay for the dental services. You say that you are devastated that your insurance has denied every charged. You also say that you cannot afford to pay for this. The Plan denied your request. The Plan says the limited oral evaluation, x-rays, scaling and root planing, and localized delivery of antimicrobial agents are not listed as covered dental 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, the services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray (D0220), additional periapical x-ray (D0230), scaling and root planing (D4342), and localized delivery of antimicrobial agents (D4381) provided from September 28, 2021, to October 15, 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 September 23, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. 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 physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) 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 the 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 September 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy provided on September 23, 2021.
You asked the Plan to waive the copayment for an endoscopy. You say that you should not have a copayment since you had another procedure at the same time. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for an endoscopy. You have been asked to pay a $350 copayment for an endoscopy. An endoscopy falls within the Outpatient Hospital Services benefit category. Although you may have had another procedure done on the same day, you can only be charged one copayment for that day. 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 an endoscopy provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder detect test (0012M) provided to the enrollee on August 27, 2021.
You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. The Plan says non-coverage of code 0012M for Cxbladder was reaffirmed by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the CxBladder testing is not covered at this time. Neither Medicare nor the health plan covers this test at this time. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder detect test (0012M) provided to the enrollee on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) and the chronic care management services (99490) rendered by the out-of-network (OON) provider on October 5, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) and the chronic care management services (99490) rendered by the out-of-network (OON) provider on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visit and the electrocardiogram (EKG) you had on July 28, 2021.
You asked the Plan to waive the copayments for the urgent care visit and the EKG. You say that you experienced constipation from anesthesia used during surgery. You said that the surgery was covered at 100%, so these services should be covered 100% as well. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the EKG, because the allowed amount for this service ($7.41) 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 a $35 copayment for urgent care visits and a $15 copayment for EKGs.
You have been asked to pay a $35 copayment for the urgent care visit and a $15 copayment for the EKG. These copayments apply even if these services were related to a surgery you had. 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 the urgent care visit and the electrocardiogram (EKG) you had on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on September 29, 2021.

You asked the Plan to pay for the core buildup. You say that this procedure was absolutely necessary. You also say that the Plan could have at least paid the cost of a conventional filling. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on September 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from August 30, 2021, through September 28, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the member required no nursing services, which would be considered skilled services by Medicare.
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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. The records did not document the need for intravenous medications or complex wound care. This enrollee did require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. As a practical matter, the enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case (with part-time therapy provided) from
August 30, 2021, through September 28, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from August 30, 2021, through September 28, 2021.