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

We decided that the Plan does not have to pay for the electrocardiographic services provided on June 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the enrollee was seen for monitoring and reading. The Plan denied your request. The Plan says prior authorization was not 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the electrocardiographic services provided on June 9, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.
You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are medically stable and have been provided medical clearance to undergo this elective procedure.
The planned procedure is not listed on the Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an intravenous ultrasound and related procedures for the enrollee.
You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary. The Plan denied your request. The Plan says that a review of the current medical literature indicates that this service or item is considered to be reasonable and necessary when there is documentation of certain conditions.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ultrasound. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is no requirement for computed tomography (CT) or magnetic resonance imaging (MRI) prior to this requested intravenous ultrasound. The vascular surgeon points out the persistence of symptoms despite the venous ablation procedures and gives a detailed analysis and argument supported by literature for the exam. Based upon these considerations a CT or MRI would not be necessary prior to the requested procedure. The exam is no longer experimental and is fairly commonly done in patients with possible May-Thurner syndrome. 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 ultrasound have been met. Therefore, we decided that the Plan has to pre-approve an intravenous ultrasound and related procedures for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation rendered on April 13, 2021.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. The file shows that the blood smear interpretation was not provided to a hospital inpatient.
Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation rendered on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), first intraoral
periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), and prophylaxis (D1110)
provided on June 11, 2021, by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, intraoral periapical x-rays, and prophylaxis.
You say that you asked the provider's office multiple times if they accepted your insurance and you were told
they did. You also say that you feel you should not be held responsible for this bill because you would not have
gone to this provider if they had advised that they did not accept your insurance. The Plan denied your request.
The Plan says this claim was processed at the OON level with a $0 copayment. The Plan also says that the nonparticipating
provider can bill you the difference between what they billed and what was paid by the 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, you are responsible for the difference
between the billed amount and allowed amount for dental services received OON. Therefore, we decided that
the Plan does not have to pay more for the periodic oral evaluation (D0120), first intraoral periapical x-ray
(D0220), two additional intraoral periapical x-rays (D0230 x2), and prophylaxis (D1110) provided on June 11,
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for glycosylated hemoglobin testing (83036) and a clinic visit
(G0463) provided on March 29, 2021.
You asked the Plan to pay for glycosylated hemoglobin testing and a clinic visit. You say that these services
should be covered because the enrollee is established with this provider. The Plan denied your request. The
Plan says these services cannot be paid 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. Medicare rules also say that claims submitted
where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the
MUE for CPT code 83036 is 1. The MAI value for this code is 2. 1 unit of this code was previously billed and
paid for this date of service. We have also confirmed that code G0463 has a bundled relationship with code
96413 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for glycosylated hemoglobin testing (83036) and a clinic visit (G0463) provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services rendered by the out-of-network (OON) provider on April 15, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the outpatient surgery services rendered by the out-of-network (OON) provider
on April 15, 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to the LTACH.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to the LTACH.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently,
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray services provided on March 30, 2021.
You asked the Plan to pay for the services provided. You say that the procedure was rendered in an appropriate place of service. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim at issue shows a place of service as an outpatient hospital. The records in the case file indicate the enrollee was an inpatient at the time the services were provided. 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 chest x-ray services provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on May 12, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the claim for
services processed correctly.
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 G0483 is definitive drug testing of 22 or more drug
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records
provided do not indicate the testing was ordered due to medication inefficacy, indications of illegal drug use, or
documented changes in affect or behavioral patterns. Based on this information, we decided that Medicare rules
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay
for the definitive drug testing provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for headgear used with positive airway pressure device (A7035), chinstrap (A7036), tubing with integrated heating element (A4604), and disposable filter (A7038), provided on February 25, 2021.
You asked the Plan to pay for headgear used with positive airway pressure device, chinstrap, tubing with integrated heating element, and disposable filter. You say that the items should be covered. The Plan denied your request. The Plan says the enrollee did not purchase the items through a participating provider.
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 headgear used with positive airway pressure device (A7035), chinstrap (A7036), tubing with integrated heating element (A4604), and disposable filter (A7038), provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the crown provided on May 26, 2021.
You asked the Plan to fully pay for the crown. You say that you requested the estimate before making the appointment to be sure the entire amount was covered. You say that you were not told the provider was out-of-network and the non-covered amount will be a burden. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the allowed amount for a crown from an out-of-network provider. You are responsible for any amount greater than the payment made by the Plan. Therefore, we decided that the Plan does not have to fully pay for the crown provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing provided on June 3, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you missed several regular preventive dental cleanings and needed this deep cleaning. You say that you were advised the cleaning was necessary and the claim should be reprocessed. The Plan denied your request. The Plan says the service is 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 the periodontal scaling and root planing provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on February 3, 2021.
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 procedure codes 01484 and 64447 are not supported.
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 01484 is anesthesia for open procedures on bones of lower leg, ankle, and foot; osteotomy or osteoplasty of tibia and/or fibula. The definition of code 64447 is injection(s), anesthetic agent(s) and/or steroid; femoral nerve. We find that CPT codes 01484 and 64447 are not supported in the medical record. Specifically, there is no documentation of 168 units of billed code 01484. Code 64447 is a column II code with a modifier of 1 when billed with code 01484 and is also not covered. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services rendered on February 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on November 17, 2020.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says there is insufficient documentation to determine if Medicare coverage has been met.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
The definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing). The definition of code 97140 (1 unit)- manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.
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 physical therapy services. Our reviewer says that this does not meet criteria for coverage. Our reviewer found that the therapy visit documents the billed codes were performed, however, time was not documented for each procedure. Our reviewer says that each procedure requires a time spent but the time cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on October 23, 2020.
You asked the Plan to pay for anesthesia for patient of extreme age (99100). You say that the Plan should pay
this claim. The Plan denied your request. The Plan says this is a bundled code an no separate payment is made
per Medicare guidelines.
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 has a Status Code of B, Bundled Code. Payment for this service is always
bundled into payment for other services. Based on this information, we decided that Medicare rules for
coverage of anesthesia for patient of extreme age (99100) have not been met. Therefore, we decided that the
Plan does not have to pay for anesthesia services provided on October 23, 2020.