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

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 27, 2020 to May 1, 2020.  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 the records do not support the billing of DRG 193 and secondary diagnosis J96.01.  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 193 (simple pneumonia and pleurisy with mcc) and secondary diagnosis J96.01 (acute respiratory failure with hypoxia). 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 these services. Our reviewer says that the records do not support the billing of DRG 193 and secondary diagnosis J96.01. Our physician reviewer found the enrollee presented to the hospital for worsening shortness of breath after a recent stroke. He was discharged two days prior for possible aspiration pneumonia. He was admitted for a pulmonary mass, post-obstructive pneumonia, and lytic lesions of bone on x-ray. The ER provider states that "pulmonary effort is normal. No respiratory distress." The requirements for acute respiratory failure are not met and the billing of DRG 193 and secondary diagnosis J96.01 are not supported.   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 services rendered from April 27, 2020 to May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the ketorolac thomethamine and methylprednisone acetate injections you received on June 19, 2021.  You asked the Plan to waive the coinsurance for the ketorolac thomethamine and methylprednisone acetate injections. You say that there should be no charge for a primary care visit. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  You were not charged for the visit itself, but there is separate cost sharing for any drugs you receive.  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 20% coinsurance for Medicare Part B drugs.      You have been asked to pay 20% coinsurance for the ketorolac thomethamine and methylprednisone acetate injections. The ketorolac thomethamine and methylprednisone acetate injections fall within the Medicare Part B drugs 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 coinsurance for the ketorolac thomethamine and methylprednisone acetate injections you received on June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an alternating pressure mattress 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 this is covered when a full treatment plan is provided.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the medical records do not support proper offloading and there is concern regarding the enrollee's non-compliance with a diabetic diet. The LCD states the enrollee must have a Stage 2 pressure ulcer on her trunk or pelvis. The only staged ulcer in the medical records is a Stage 3 on her right thigh, which does not meet LCD criteria. The review has determined that the enrollee does not have either:-multiple stage II pressure ulcers located on the trunk or pelvis, which have been treated in a comprehensive program-large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis, or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days.  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 an alternating pressure mattress for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for intermittent limb compression device.  You asked the Plan to pay for intermittent limb compression device. You say that the device is medically necessary. The Plan denied your request. The Plan says the enrollee has not been diagnosed with lymphedema or chronic venous insufficiency with venous stasis ulcers.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from provided from May 11, 2021, through May 17, 2021.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of services provided from May 11, 2021, through May 17, 2021 are not medically necessary due to no daily skilled needs.

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 documentation provided, the health Plan's denial of SNF coverage should be upheld. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, 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 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 May 11, 2021, through
May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a semi-electric hospital bed.  You asked the Plan to pre-approve the bed. You say that you would like to limit the distance between standing and sitting. The Plan denied your request. The Plan says the guidelines were not met.  The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:  1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  2. Requires attachments which can only be attached to a hospital bed; AND  3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for you.  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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a laparoscopy provided on May 20, 2021.  You asked the Plan to waive the copayment for a laparoscopy. You say that you do not understand why the surgery charges are so much higher than other surgeries you have received. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You received a laparoscopy on May 20, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $861.26 and 20% of that is $172.25.   You have been asked to pay the total coinsurance amount of $172.25 for a laparoscopy. A laparoscopy 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 a laparoscopy provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two pairs of eyeglasses (V2744, V2755, V2201, V2020) purchased on May 24, 2021.
You asked the Plan to pay for the eyeglasses. You say that the cost of your eyeglasses was less than the Plan's annual allowance, so you should be reimbursed the full cost of these items. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's vision vendor network. Routine vision services obtained from vendors outside this network are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 for one pair of eyeglasses every year when they are purchased from a provider in the Plan's vision vendor network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for two pairs of eyeglasses (V2744, V2755, V2201, V2020) purchased on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on May 20,
2021.
You asked the Plan to waive the coinsurance for laboratory services. You say that you disagree with 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 $0
copayment for laboratory services provided in a primary care provider's office, specialists office or freestanding
laboratory and 20% coinsurance when provided at an outpatient hospital facility.
You received laboratory services on May 20, 2021, at an outpatient hospital facility. Therefore, you are
responsible to pay your share of the cost-sharing charges. The total allowed amount is $35.81 and 20% of that
is $7.16.
You have been asked to pay $7.16 for laboratory services. Laboratory services 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
coinsurance for laboratory services provided on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiology services (74230) provided on July 22, 2021.  You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 22. According to claims history, the radiology service (74230) was obtained while the enrollee was in an inpatient hospital setting. Therefore, we decided that the Plan does not have to pay for the radiology services (74230) provided on July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 22, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed
incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or
proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we
decided that the Plan does not have to pay for the genetic testing provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on August 3, 2021.

You asked the Plan to pay for the topical application of fluoride varnish. You say that you told the provider you had been without insurance for two years and your teeth had not been cleaned. You also say that you were told you needed under the gum cleaning. The Plan denied your request. The Plan says fluoride varnish (D1206) is not a supplemental benefit.

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 topical application of fluoride varnish (D1206) provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CALR (calreticulin) gene analysis provided on December 17, 2020.  You asked the Plan to pay for the CALR (calreticulin) gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The the CALR (calreticulin) gene analysis test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the CALR (calreticulin) gene analysis provided on December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the instillation of fibrinolytic agents using catheters and the removal of a catheter provided from May 24, 2021, and June 23, 2021.  You asked the Plan to waive the copayments for the instillation of fibrinolytic agents using catheters and the removal of a catheter. You say that you disagree with the charges because you believe that the procedures should not be considered as outpatient surgeries. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  The enrollee received the instillation of a fibrinolytic agent at an outpatient hospital facility on May 24, 2021.  The instillation of a fibrinolytic agent is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the $400 copayment.   The enrollee received the instillation of a fibrinolytic agent at an outpatient hospital facility on June 9, 2021.  The instillation of a fibrinolytic agent is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the $400 copayment.  The enrollee received the removal of a catheter at an outpatient hospital facility on June 23, 2021. The removal of a catheter is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the $400 copayment.   The total amount the enrollee owes is: $1,200.   The enrollee has been asked to pay the total copayment amount of $1,200 for the instillation of fibrinolytic agents using catheters and the removal of a catheter. The instillation of fibrinolytic agents using catheters and the removal of a catheter fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the instillation of fibrinolytic agents using catheters and the removal of a catheter provided from May 24, 2021, and June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (S1015, S8301) provided on May 13, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.   We looked at the file and Medicare rules. Code S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (S1015, S8301) provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable home ventilator (E0466).  You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our reviewer says that the requested ventilator is not medically necessary. Our physician reviewer found the records show the enrollee did very well on BiPAP. It has not been demonstrated that ahome ventilator is 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (13102) provided on March 4, 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 13102 is a column II code to column I code 13100. 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 services (13102) provided on March 4, 2021.