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

We decided that the Plan does not have to pre-approve the X-Stop device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare
due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. X-stop remains
experimental in spine surgery. More research is needed to show safety and efficacy. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the X-Stop device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image
(D0350) and complete series of intraoral x-rays (D0210), or waive the copayments for the comprehensive oral
evaluation (D0150), crown (D2751), and core buildup, including any pins when required (D2950) provided on
July 14, 2021.
You asked the Plan to pay for the 2D oral/facial photographic image and complete series of intraoral x-rays,
and to waive the copayments for the comprehensive oral evaluation, crown, and core buildup. You say that you
believe you overpaid this treating provider, and you would like any money that was overpaid to be given back
to you. The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered
service, and your limitation has been met for the complete series of intraoral x-rays. The Plan also says that you
are responsible for a $0.00 copayment for the comprehensive oral evaluation, a $325.00 copayment for the
crown, and a $42.00 copayment for the core buildup.
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, 2D oral/facial photographic image
(D0350) is not among those covered under this benefit. The contract says that you are limited to up to one (1)
full set of dental x-rays every three (3) years. The record shows that you received a complete series of intraoral
x-rays (D0210) on October 20, 2020 and your full set of dental x-rays benefit has been exhausted. You are also
responsible for a $0.00 copayment for the comprehensive oral evaluation (D0150), a $325.00 copayment for
the crown (D2751), and a $42.00 copayment for the core buildup, including any pins when required (D2950).
Therefore, we decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic
image (D0350) and complete series of intraoral x-rays (D0210), or waive the copayments for the
comprehensive oral evaluation (D0150), crown (D2751), and core buildup, including any pins when required
(D2950) provided on July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration coded 99601
provided on May 3, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 99601 is home infusion/specialty drug administration, per
visit (up to 2 hours).
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status code of
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the home infusion/specialty drug administration have not been met. Therefore, we decided that the
Plan does not have to pay for the home infusion/specialty drug administration coded 99601 provided on May 3,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy through stoma; with control of bleeding,
any method (CPT code 44391-59) provided to the enrollee on June 29, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not supported by the records.
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 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 the service. Our reviewer found the documentation does not
support that the colonoscopy on June 29, 2021, was performed through a stoma, nor do the records support that
bleeding was controlled.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not
have to pay for the colonoscopy through stoma; with control of bleeding, any method (CPT code 44391-59)
provided to the enrollee on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care you received on August 17, 2021.
You asked the Plan to pay for the foot care. You say that you cannot take care of your own feet. The Plan
denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails.
The records do not show that any of these conditions are present. The services you are asking the Plan to pay
for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the
foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care
you received on August 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 26, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on August 25, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services
provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from October 12, 2020, to October 15, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not supported.

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 diagnosis code J96.10. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of diagnosis code J96.20 is not supported by the records provided. Our physician reviewer found that the documentation supported an admission for pneumonia. The documentation did not support the diagnosis of Respiratory Failure. Even though Respiratory Failure is documented throughout the medical record, supporting documentation was not found within the record. 

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 services provided from October 12, 2020, to October 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit (up
to 2 hours) (CPT code 99601) provided to the enrollee from July 8, 2021, through July 26, 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 this service is not covered by Medicare or the health plan.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code 99601 has a status code "I" 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
home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the
enrollee from July 8, 2021, through July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0427, A0425) provided on September 6, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this cost is too high,
especially with your other medical bills. The Plan denied your request. The Plan says this claim was processed
correctly, and your copayment was assessed in accordance with your contract.
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 $325
copayment for ambulance services.
You have been asked to pay a $325 copayment for the ambulance services. 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 the ambulance transportation services (A0427,
A0425) provided on September 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for an inpatient hospital stay provided by an out-of-network provider on March 19, 2021, to March 21, 2021.

You asked the Plan to waive the deductible and coinsurance for an inpatient hospital stay. You say that you were told that everything was going to be covered. The Plan denied your request. The Plan says the correct charges have been applied.

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 $1,000 deductible and a 30% coinsurance for inpatient hospital care/out-of-network. 

You have been asked to pay a $483.06 deductible and a 30% coinsurance of the allowed amount for an inpatient hospital stay. The total allowed amount is $9,353.22.

The total coinsurance amount is $2,805.97 ($9,353.22 x 30% = $2,805.97). The total amount you are being asked to pay is $3,289.03 ($483.06 + $2,805.97 = $3,289.03). The correct charges have been applied to the inpatient care that was provided. An inpatient hospital stay falls within the inpatient hospital care/out-of-network 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 deductible and coinsurance for an inpatient hospital stay provided by an out-of-network provider on March 19, 2021, to March 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) June 6, 2021.

You asked the Plan to reduce the copayment for the emergency ambulance services. You say that the last EOC your received said the copayment for ambulance services is $110. The Plan denied your request. The Plan says the copayment was applied 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 $225 copayment per day for Medicare-covered ambulance round-trip services. 

You have been asked to pay a $225 copayment for the emergency ambulance services. The emergency ambulance services fall within the Ambulance services 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 reduce the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) June 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses and retinal screening photography provided on
July 27, 2021.
You asked the Plan to pay for contact lenses and retinal screening photography. The Plan denied your request.
The Plan says you received the contact lens benefit on January 5, 2021, and retinal screening photography is
not a covered benefit.
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 contact lenses every year.
We looked at the file and the Plan's rules. The file shows that you used the routine eyewear benefit on
January 5, 2021 and the Plan does not provide coverage for retinal screening photography. Therefore, we
decided that the Plan does not have to pay for contact lenses and retinal screening photography provided on
July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 1, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like the Plan to pay for this. The Plan denied
your request. The Plan says the referring provider is out-of-network. The Plan says that there are in-network
providers available who could have provided these services.
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 lab work provided on September 1, 2021, by an
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code
70544) provided to the enrollee on September 5, 2021.
You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request.
The Plan says the 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. In this case, we have confirmed that code 70551
is a column II code to column I code 70544. 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 MRA, head; without contrast material(s) (CPT code 70544)
provided to the enrollee on September 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network telehealth services provided on March 25,
2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.
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 out-of-network
telehealth services are not covered.
Review of the file shows that out-of-network telehealth services were provided to the enrollee on March 25,
2021. These services are not covered by the Plan. The Plan only covered telehealth services rendered by in-
network providers. Therefore, we decided that the Plan does not have to pay for the out-of-network telehealth
services provided on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83450, 83550, 83970, 84100) provided to the enrollee on March 4, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 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 laboratory services have not been met. The documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of ESRD. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83450, 83550, 83970, 84100) provided to the enrollee on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0425, A0428) provided on August 10, 2021.
You asked the Plan to waive the copayment for the ambulance trips. You say that you thought that the group
who scheduled the ride for you would be responsible for this cost, and you feel this should have only one
copayment because you were told this was considered a round trip. The Plan denied your request. The Plan
says this claim was processed correctly, and your copayments were applied in accordance with your contract.
You are responsible for a $350 copayment for each Medicare-covered ambulance trip.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for each Medicare-covered ambulance trip.
You have been asked to pay a $350 copayment for each of the ambulance trips. A trip is considered to be
transportation from one location to another location. A round trip is two trips. 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 the ambulance transportation services (A0425, A0428) provided on August 10,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device placement for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered
by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertilfex device
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vertiflex device placement for the enrollee.