Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam and fundus photography
provided on August 30, 2021.

You asked the Plan to waive the copayment for the eye exam and fundus photography. You say that you were
not aware of any additional copayment for the additional service. 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 $15
copayment for each basic eye exam. If the doctor provides you services in addition to the eye exam, separate
cost-sharing of up to $35 may apply.

You have been asked to pay a $15 copayment for the eye exam and $35 for the fundus photography, for a visit
total of $50. The eye exam and fundus photography fall within the Vision 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 an eye exam and fundus photography provided on August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal puncture (62270) provided on September 7, 2021.
You asked the Plan to pay for the spinal puncture (62270). You say that modifier 79 is appropriate for CPT code 62270. You say that the clinical notes should be reviewed, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says modifier 79 is not appropriate as there were no other major procedures reported by the same Tax ID and specialty within the post-operative period.
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 62270 is spinal puncture, lumbar, diagnostic.
We find that CPT code 62270 is not supported in the medical record. Specifically, an incorrect modifier was
billed with CPT code 62270. Based on this information, we decided that Medicare rules for coverage of the
spinal puncture (62270) have not been met. Therefore, we decided that the Plan does not have to pay for the
spinal puncture (62270) provided on September 7, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided on July 1, 2021.
You asked the Plan to pay for home infusion service. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because codes 99601 and 99602 are not valid for Medicare purposes and are not payable.
The Plan must follow Medicare rules. Medicare rules say that codes 99601 and 99602 are not valid for Medicare purposes and are not payable.
We looked at the file and Medicare rules. The billed codes are not valid for Medicare purposes and are not payable. Based on this information, we decided that Medicare rules for coverage of home infusion service have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, spine, cervical, (72040) application of a modality to 1 or more areas; hot or cold packs (97010) provided September 8, 2021.
You asked the Plan to pay for the chiropractic services. You say that you need this bill paid. You did not know the Plan would not pay for it. You needed the x-rays so the chiropractor can help. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for radiologic examination, spine, cervical, (72040) application of a modality to 1 or more areas; hot or cold packs (97010) provided September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on June 25, 2021.

You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services are not payable.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code.

We looked at the file and Medicare rules. The PET scan in this case was not billed with an appropriate diagnosis code as required by Medicare rules. The PET scan is not payable when billed with diagnosis code F03.90. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric services provided from August 1, 2020, through January 29, 2021.

You asked the Plan to pay for inpatient psychiatric services. The Plan denied your request. The Plan says inpatient psychiatric services provided from August 1, 2020, through January 29, 2021 are not medically necessary.

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 inpatient psychiatric services provided from August 1, 2020, through January 29, 2021. Our reviewer says that the inpatient psychiatric services were not medically necessary. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. 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 as he did not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. The health Plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others, no auditory or visual hallucinations. He is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services provided from August 1, 2020, through
January 29, 2021. have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric services provided from August 1, 2020, through January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Horizant.
Benefits for this drug 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) and individual psychotherapy
(90833) provided on August 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this provider has been treating you for 10 years and
you have never received a denial. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99213) and individual
psychotherapy (90833) provided on August 16, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #8.

You asked the Plan to pre-approve the crown. You say that you are having a hard time chewing and are unable to eat solid foods. The Plan denied your request. The Plan says this service is not medically necessary because your teeth are not healthy due to large cavities or poor bone around your teeth.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #8.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the brain stem provided on September 20, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you feel that the MRI should be included in your emergency room visit since it was requested at that 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 $300 copayment for outpatient diagnostic tests, including MRI's. You have been asked to pay $214.18, which is less than the $300 copayment for the MRI. The MRI falls 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 copayment for magnetic resonance imaging (MRI) of the brain stem provided on September 20, 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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.
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.
The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture
after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there
is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF
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 waive the copayments for the injection and palmar fascial cord manipulation provided on August 24, 2021, and August 27, 2021.

You asked the Plan to waive the copayments for the injection and the palmar fascial cord manipulation. You say that you believe these were not office visits but procedures. You say you should not be billed for office visits which require copayments. The Plan denied your request. The Plan says you have been asked to pay 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 $15 copayment for services obtained from a specialist or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. 

You have been asked to pay a $15 copayment for the injection and a $15 copayment for the palmar fascial cord manipulation. The injection and the palmar facial cord manipulation fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record shows the injection, and the palmar fascial cord manipulation are physician services that were performed in the physician's office.

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 injection and the palmar fascial cord manipulation provided on August 24, 2021, and August 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous implantation of neurostimulator electrode
array, epidural (Current Procedural Terminology (CPT) code 63650 x 2), for the enrollee.
You asked the Plan to pay for the services. You say that the enrollee has intractable back pain that cannot be
controlled without the upgrading or revising of the enrollee's permanent percutaneous stimulator and battery.
The Plan denied your request. The Plan says this service is 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.
This is the incorrect code for the wire change in clinical scenario. The Plan states the correct codes for the wire
change (CPT 63663 x 2) have been approved. 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
percutaneous implantation of neurostimulator electrode array, epidural (Current Procedural Terminology (CPT)
code 63650 x 2), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300).
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The
Plan denied your request. The Plan says the item is not covered.
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 item have not been met. The rules say that a power seat
elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily
medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if
the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as
non-covered. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system
(CPT code E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria.
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 complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for. pancreatitis. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing coded as 95870, 95938 and 95957 provided December 11, 2020.
You asked the Plan to pay for the diagnostic testing. You say that this claim is for the technical charges. You are not a part of the facility, nor do you bill your services with or to the facility. The Plan denied your request. The Plan says the services were billed by and paid to another provider for this 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 find that CPT codes 95870, 95938 and 95957 are not supported in the medical record. Specifically, this provider is a specialist/technologist that is not recognized as a legally qualified physician.
Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the services. Based on this information, we decided that Medicare rules for coverage of the diagnostic testing have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic testing coded as 95870, 95938 and 95957 provided December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on June 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 01992
is a column II code to column I code 64493. 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 anesthesia services provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on September 2, 2021, by an
OON provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to
verify eligibility and obtain authorization. You say the service was medically necessary. The Plan denied your
request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the domiciliary visit provided on September 2, 2021, by an OON
provider.