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

 We decided that the Plan does not have to pay for angiography and sedation services provided on April 23, 2021.  You asked the Plan to pay for angiography and sedation services. You say that these services were rendered appropriately in response to the enrollee's medical condition. The Plan denied your request. The Plan says the denial of payment for these services is correct, because codes 75726 and 75774 do not meet criteria for separate reporting and code 99152 is bundled into all radiation therapy services.  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 75726 is angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation. The CPT Code Manual definition of code 75774 is angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.  We asked our coder 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 angiography and sedation services. Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found the records provided do not include sufficient documentation to validate separate reporting of an Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation on April 23, 2021, therefore procedure code 75726 cannot be verified. The medical records provided does not include sufficient documentation to validate separate reporting of an Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) on April 23, 2021, therefore procedure code 75774 cannot be verified. CPT 99152 falls into the code range 99152 - 99153 that bundles these procedures in radiation therapy services.  Based on this rule and the medical records provided, CPT 99152 is not eligible for separate reimbursement.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of angiography and sedation services have not been met. Therefore, we decided that the Plan does not have to pay for angiography and sedation services provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5050) purchased on January 21, 2021.  You asked the Plan to pay for the hearing aids. You say that this is a legitimate provider and you do not understand why this claim is being denied. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's routine hearing provider network as specified in the contract. Hearing aids purchased outside of the specified routine hearing network are not covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's specified routine hearing vendor network.   We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5050) purchased on January 21, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency department services provided on January 27, 2020.

You asked the Plan to pay for emergency department services. You say that your records show that you
submitted this claim in a timely manner. The Plan denied your request. The Plan says that the denial of
payment for these services is correct, because the time limit for submitting this claim expired.

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 follows Medicare rules. The rules say that claims for services furnished on or after January
1, 2010, must be filed no later than one calendar year after the date of service.

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 did not provide evidence showing that this claim was submitted more
than 1 calendar year after the date of service. You say that you submitted this claim within the timely filing
limit. Without supporting evidence, the Plan has not shown that its decision to deny payment for these services
is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for
emergency department services provided on January 27, 2020.

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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) stay August 10, 2021 to September 8, 2021.  You asked the Plan to pre-approve the SNF stay. You say that you feel that the Plan should cover for the continued SNF level of coverage. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) stay August 10, 2021 to September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by an out-of-network provider on June 30, 2021.  You asked the Plan to pay for a resin-based composite. You say that you were in a lot of pain and needed this dental work. The Plan denied your request. The Plan says the dental work that was provided was not a covered 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 a resin-based composite (D2332) provided by an out-of-network provider on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lumbar epidural injection.  You asked the Plan to pre-approve a lumbar epidural injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered for certain indications.  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 a lumbar epidural injection. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of low back pain with neurogenic claudication secondary to lumbar spinal stenosis. There is no documentation provided indicating the enrollee has had a failure of non-surgical, non-injection/ conservative care, which includes appropriate oral medications and physical therapy to the extent tolerated. Therefore, the enrollee does not meet criteria for the requested services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the denture (D5863), provided on May 14, 2021.  You asked the Plan to pay for the denture. You say that this service should be covered. The Plan denied your request. The Plan says this is not a covered 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 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 denture (D5863), provided on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and more stable but still requires short-term additional acute care services that can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility.  Transfer to the LTACH is not supported and would not be clinically advantageous due to the enrollee's poor prognosis and likely need for only short-term additional acute care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021.

You asked the Plan to pay for the laboratory 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. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.

Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided you only require short-term additional acute care services that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve continued SNF services after December 12, 2021.  You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan denied your request. The Plan says that continuation of SNF care is not medically necessary.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before December 12, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued SNF services after December 12, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 9, 2021, to July 13. 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that if you had been approved for surgery earlier, you may not have needed the emergency surgery that was part of this inpatient stay. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $492 copayment per day for days 1-4 for inpatient hospital care.   Records show that you were in the hospital for 3 days.  You were charged a $492 copayment per day, for a total of $1476. This copayment applies regardless of the reason for your inpatient stay. 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 inpatient hospital services you received from July 9, 2021, to July 13. 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Aflibercept and Bevacizumab injections you received on July 28, 2021.

You asked the Plan to waive the coinsurance for the Aflibercept and Bevacizumab injections. You say that you were told that you would only be responsible for a $10 copayment. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% coinsurance for Medicare Part B drugs. 

You have been asked to pay 10% coinsurance for the Aflibercept and Bevacizumab injections. The Aflibercept and Bevacizumab injections falls 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 Aflibercept and Bevacizumab injections you received on July 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (CPT code 99233) provided to the enrollee on February 15, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that this claim was correct, and documentation supplied did not support adjustments.
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. Review of the explanation of benefits shows that this claim denied due to being an exact duplicate claim/service; however, there is not enough information from the plan to verify that this is a duplicate. Therefore, we decided that the Plan has to pay for subsequent hospital care (CPT code 99233) provided to the enrollee on February 15, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walking boot (L4361), provided on May 10, 2021.

You asked the Plan to pay for a walking boot. You say that the item is medically necessary. The Plan denied your request. The Plan says the medical records submitted don't contain any documentation of medical necessity, office notes from the prescribing provider on the date of service or in the 6 months prior to date of service.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a walking boot (L4361), provided on May 10, 2021.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pay for the needle electromyography (95870), short-latency somatosensory evoked potential study (95938), central motor evoked potential study (95939) and continuous intraoperative neurophysiology monitoring (G0453) provided on July 14, 2021.  You asked the Plan to pay for the needle electromyography, short-latency somatosensory evoked potential study, central motor evoked potential study and continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the facility charges include intraoperative neurophysiology monitoring services  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any evidence that payment has been made for these services. Additionally, these services are for the professional component which is separately reimbursable. Therefore, we decided that the Plan has to pay for the needle electromyography (95870), short-latency somatosensory evoked potential study (95938), central motor evoked potential study (95939) and continuous intraoperative neurophysiology monitoring (G0453) provided on July 14, 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.