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

 We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided by an out-of-network provider on April 24, 2021, to April 30, 2021.  You asked the Plan to waive the copayment for an inpatient mental health stay. You say that this provider is in-network, and you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has 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 $295 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient mental health care.     You have been asked to pay a $295 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient mental health stay. The total amount you are being asked to pay is $1,475 ($295 x 5 days = $1,475). The same cost sharing amount is applied to in-network and out-of-network providers. An inpatient mental health stay falls within the inpatient mental health 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 inpatient mental health stay provided by an out-of-network provider on April 24, 2021, to April 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. The enrollee's care needs are long-term and custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a diagnostic or therapeutic injection.  You asked the Plan to pre-approve a diagnostic or therapeutic injection. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered medically reasonable and necessary when specific criteria are met.  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 diagnostic or therapeutic injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have radicular symptoms and has multiple compression fractures. The request does not meet the LCD criteria for this procedure. Therefore, it is deemed not be medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic or therapeutic injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from September 22, 2020 to September 25, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment of DRG 871 is not supported, as a review supports DRG 178. 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 . 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 services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the documentation supported an admission for pneumonitis. The documentation was unclear regarding these diagnoses. Even though sepsis is documented throughout the medical record and respiratory failure was noted on the discharge summary, supporting documentation was not found. The appeal mentions the enrollee met Sepsis 2 criteria and there is no listed argument for respiratory failure. There was no evidence of a rise in SOFA of 2 or more points that cannot be easily explained by causes other than sepsis. The enrollee was given 1 SOFA for hypotension post IV fluid bolus. The enrollee was diagnosed with pneumonitis. The review has determined that payment of DRG 871 was not supported. The review supports DRG 178.   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 inpatient hospital services provided to the enrollee from September 22, 2020 to September 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on June 22, 2021.  You asked the Plan to pay for the medical equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these codes are not eligible for payment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.   We find that CPT codes S1015 and S8301 are not eligible for payment per Medicare rules. Specifically, these codes both have a status indicator of "I" which indicates that the codes in question are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on June 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation services (A0428) provided on July 26, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is a covered benefit, and your copayment was assessed in accordance with your contract. Ambulance services require a $250 copayment. Because the allowed amount (Plan's discounted rate) for the services in this case is less than this amount, you are responsible for a $229.62 copayment.  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 $250 copayment for ambulance services.   You have been asked to pay a $229.62 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 non-emergent ambulance transportation services (A0428) provided on  July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and therapeutic parenteral drug, single administration (D9610) provided June 14, 2021.  You asked the Plan to pay for the intraoral x-rays and therapeutic parenteral drug. You say that you believed the provider was in the Plan's network. The Plan denied your request. The Plan says the claims from this date have been reprocessed as in-network, however these services are not covered under your 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 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 intraoral - complete series of radiographic images (D0210) and therapeutic parenteral drug, single administration (D9610) provided June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for intravenous (IV) tubing extension set (S1015) and infection control supplies (S8301) provided on June 24, 2021.  You asked the Plan to pay for IV tubing extension set and infection control supplies. You say that yr request. The Plan says the denial of payment for these supplies is correct, because these codes are not valid for Medicare purposes and are not payable.  The Plan must follow Medicare rules. Medicare rules say that codes S1015 and S8301 are not valid for Medicare purposes and are not payable.   We looked at the file and Medicare rules. These codes are not valid for Medicare purposes and are not payable. Based on this information, we decided that Medicare rules for coverage of IV tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for intravenous (IV) tubing extension set (S1015) and infection control supplies (S8301) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluoroscopic guidance for spine or back muscle injection (77003) provided on January 25, 2021.  You asked the Plan to pay for the fluoroscopic guidance for spine or back muscle injection. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been billed with one of the listed primary procedure codes as required by Medicare rules.  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 77003 is an add-on code and has not been billed with an appropriate primary procedure code. 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 fluoroscopic guidance for spine or back muscle injection (77003) provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on December 9, 2020.  You asked the Plan to pay for the services provided. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for suspected or documented cardiovascular disease.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  We looked at the file and the rules. The records provided do not indicate the testing was ordered due to signs and symptoms that warranted further testing. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for out of network services provided to the enrollee on July 20, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided to the enrollee on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 9, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.      We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core build-up (D2950) and crown (D2752) for tooth #14 and tooth #19.  You asked the Plan to pre-approve a core build-up and crown. You say that due to new and recurrent decay, hairline fractures and compromised margins surrounding previous restoration, the enrollee has extreme sensitivity and discomfort with masticating. Composite resin restoration will not provide a long-term prognosis. The Plan denied your request. The Plan says there is no evidence of severe tooth destruction due to decay or trauma.  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. The Plan covers a core build-up and crown when the services are medically necessary and reasonable.   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 core build-up and crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided radiographs indicate that tooth #14 is present in the upper arch, however #19 is not present in the lower arch. Tooth #14 appears to have possibly a small distal lesion without much apparent missing structure, though the provider had noted substantial buccal and occlusal decay. Tooth #14 is readily restored with a conventional composite restoration, as it does not have apparent significant amounts of damaged structure even if there is some buccal and occlusal decay. Tooth #19 is missing and does not require further discussion. Core buildups, needed only where there is insufficient structure to retain a crown that will be placed, are also not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a core build-up and crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a core build-up (D2950) and crown (D2752) for tooth #14 and tooth #19.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 10, 2020, through January 26, 2021, billed with CAPE1.  You asked the Plan to pay for the SNF services as billed. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says there are discrepancies between the medical documentation and the services as billed.  The Plan follows Medicare rules. Medicare rules say that SNF services are billed using a HIPPS code which has four digits for four case-mix groups as described in the Medicare rules section. Calculation of the proper HIPPS code takes into account the Resident Assessment Instrument (RAI) manual and PDPM calculation worksheet, which provides guidance on completing the Minimal Data Set (MDS) assessment. Reported diagnoses in Section I of the MDS assessment are used to help determine both the nursing case-mix group (third digit of the HIPPS code) and NTA case-mix group (fourth digit). 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 SNF services as billed. Our reviewer says that the documentation does not support diabetes mellitus as a diagnosis and does not support complicated intervention of a surgical wound during the dates in question. Our physician reviewer found the enrollee is an 83-year-old woman with a medical history that included diabetes, chronic kidney disease, sleep apnea, vascular dementia, and pulmonary hypertension. The enrollee was admitted to the hospital on January 7, 2020, for a total hip replacement on the right. The enrollee was admitted to the SNF on January 10, 2020. The enrollee was doing well post-operatively. The right hip incision was healing. There were no documented incisional difficulties. The Resident Diagnosis Report does not include a diagnosis of diabetes mellitus. The medication list did not include medications to treat diabetes mellitus. The documentation does not support the performance of a complicated intervention of a surgical wound.  We looked at this physician's review, the file, and Medicare rules. Since these services are not supported, both the third and fourth digits billed of the billed HIPPS code are not supported. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 10, 2020, through January 26, 2021, billed with CAPE1.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits.  You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had prior extensive therapy and the records do not demonstrate that your functional level needs the unique skills of a professional therapist. You have been given education regarding a home exercise program and should be able to transition to an independent program at this point. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate anesthesia services (99153) provided on February 8, 2002.  You asked the Plan to pay for the moderate anesthesia services. You say that you would like this service reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services as billed are not covered.  The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.    We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate anesthesia services (99153) provided on February 8, 2002.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the detailed and extensive oral evaluation - problem focused, by report (D0160), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and pulp vitality tests (D0460) provided August 19, 2021.  You asked the Plan to pay for the extensive oral exam, cone beam CT scan and pulp vitality tests. You say that the procedures were necessary. The Plan denied your request. The Plan says these services are not covered under your 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 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 detailed and extensive oral evaluation - problem focused, by report (D0160), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and pulp vitality tests (D0460) provided August 19, 2021.