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

We decided that the Plan does not have to pay for the pathology services provided on February 1, 2021.
You asked the Plan to pay for the billed services. You say that another provider incorrectly billed the same code. The Plan denied your request. The Plan says they cannot determine whether the services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. We find that CPT code 88305 is not supported in the medical record. Specifically, records were not provided to confirm that Medicare coverage criteria have been met. The file shows that the Plan made multiple attempts to obtain additional information, with no success. Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 15, 2021.  You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with how the procedure was coded and how the claims processed. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You received arthrocentesis at an outpatient hospital facility on June 15, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.   You have been asked to pay a $350 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the pulmonary function test provided on August 18, 2021.
You asked the Plan to waive the copayment for pulmonary function test. You say that you did not have a pulmonary function test on this date of service. The Plan denied your request. The Plan says that the copayment applied correctly based on the services provided.
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. The Plan failed to forward us the medical records that would support the services being billed, we are unable to determine whether the copayment being assessed is correct. Therefore, we decided that the Plan has to waive the copayment for the pulmonary function test provided on August 18, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodic comprehensive preventive medicine
reevaluation and management of an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic
procedures, established patient; 65 years and older (CPT code 99397) provided on April 13, 2021.
You asked the Plan to pre-approve the service. You say that this visit was an OGI exam with your Obstetrics
and Gynecology (OBGYN) doctor. The Plan denied your request. The Plan says you received a routine
physical on February 4, 2021, and this provider billed the Plan for a routine physical on April 13, 2021.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. Review of the file shows that you had a routine physical on April 13,
2021. Since the health plan paid for the routine physical you had on February 4, 2021, the Plan denied your
request for reconsideration of the denial of the second annual routine physical you had in 2021. Based on this
information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we
decided that the Plan does not have to pre-approve periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic
procedures, established patient; 65 years and older (CPT code 99397) provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON)
provider on March 5, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) provider on March 5, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve caries risk assessment and documentation, with a finding of high risk (D0603).  You asked the Plan to pre-approve caries risk assessment and documentation, with a finding of high risk. You say that you disagree with the denial and you would like to appeal the decision with additional medical records submitted after the denial. The Plan denied your request. The Plan says the requested dental service is not covered by your Plan.  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 pre-approve caries risk assessment and documentation, with a finding of high risk (D0603).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on August 25, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this claim should be paid because you were referred to a dental surgeon that did not accept your insurance. The Plan denied your request. The Plan says this service exceeds the maximum allowed per 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 11, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 854
provided from December 10, 2020, to December 17, 2020.
You asked the Plan to pay for inpatient care. You say that this diagnosis code is supported by the documentation. The Plan denied your request. The Plan says the denial of payment for this inpatient stay at DRG 854 is correct, because A41.02 is not supported as the primary diagnosis and was replaced with diagnosis code L02.11.
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 A41.02 - sepsis due to methicillin resistant staphyloccocus aureus. 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 inpatient care. Our reviewer says that this inpatient stay does not meet the criteria for payment at the requested DRG 854. Our physician reviewer found based on Sepsis-3 criteria, organ dysfunction can be identified as an acute change in the total Sequential Organ Failure Assessment (SOFA) score. Documentation is not consistent with clear documentation of organ dysfunction and sepsis. Acute renal failure/chronic kidney disease stage 4 is documented; however, documentation states "No records available to confirm". Documentation suggests a possibility of sepsis; however, documentation does not support this diagnosis. 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 care at diagnosis related group (DRG) 854 provided from December 10, 2020, to December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), panoramic x-ray (D0330), prophylaxis (D1110), amalgam of three surfaces (D2160), amalgam of four or more surfaces (D2161), and first intraoral periapical x-ray (D0220) provided from May 18, 2021, to June 4, 2021.

You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, prophylaxis, amalgams, and first intraoral periapical x-ray. You say that your cancer doctor made the dental appointment for you and wanted to per you on Prolia, but your calcium is far from normal. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says dental services are not covered under the medical plan, and your dental coverage did not start until July 1, 2021. The Plan also says that you did not have any supplemental dental benefits.

Medicare generally does not cover dental services. 

The Plan follows the same rule. The services you are asking the Plan to pay for 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 pay for the periodic oral evaluation (D0120), panoramic x-ray (D0330), prophylaxis (D1110), amalgam of three surfaces (D2160), amalgam of four or more surfaces (D2161), and first intraoral periapical x-ray (D0220) provided from May 18, 2021, to June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the requested Coflex lumbar interspinous decompression device is experimental and investigational, therefore, not covered by Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on March 15, 2021.  You asked the Plan to pay for the services provided. You say that the procedure code and modifier was coded appropriately. The Plan denied your request. The Plan says this procedure is not paid separately.  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 99100 is a bundled code. Payment for this service is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from January 26, 2021, through February 1, 2021, as billed.

You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the secondary diagnosis code that will billed with these services. The Plan denied your request. The Plan says the medical records do not support the billed secondary diagnosis code.

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 secondary diagnosis code, E43, defined as unspecified severe protein-calorie malnutrition. 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 inpatient hospital care as billed. Our reviewer says that the inpatient care as billed is not supported in the medical documentation submitted. Our physician reviewer found that the patient is a 74 year old male. A secondary diagnosis code was reported, E43, defined as unspecified severe protein-calorie malnutrition. The records showed that the patient had weight loss for years related to chronic malnutrition. On this acute visit, however, he was noted as being "well nourished" on examination. There were no other indications in the provided documentation that the patient had acutely severe protein-calorie malnutrition to justify this secondary diagnosis. 

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 the inpatient hospital care provided from January 26, 2021, through February 1, 2021, as billed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services (75726 and 75774) provided on May 2, 2021.
You asked the Plan to pay for codes 75726 and 75774. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 75726 and 75774 are column II codes to column I code 37244.
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 angiography services (75726 and 75774) provided on May 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit (99213) provided on May 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that you requested an appeal for this service previously, but you never received the documentation for it. You also say that is why another appeal has been submitted. The Plan denied your request. The Plan says the service does not meet criteria for approval due to there are 9 available contracted providers in the service area that are accepting new patients. The Plan also says that authorization must be requested, and in this case, it was not.
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 specialist office visit (99213) provided on May 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for multiplex viral respiratory panel testing provided on November 13, 2020.

You asked the Plan to pay for lab test. You say that you have no knowledge of patient coverage prior to the specimen's arrival at the lab. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation indicates more than 5 targets for this testing which is non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more targets are non-covered. 

We looked at the file and Medicare rules. Although you billed the code for 3-5 targets, the record shows that this testing included more than 5 targets. Therefore, it is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for multiplex viral respiratory panel testing provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve genetic testing to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methylprednisolone.

You asked the Plan to pre-approve Methylprednisolone. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methylprednisolone.

Benefits for Methylprednisolone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on May 18, 2021.
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on May 18, 2021.