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

 We decided that the Plan does not have to pay for the preventive medicine evaluation rendered on September 3, 2021.  You asked the Plan to pay for these services. You say that the plan requested that you change your primary care doctor. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that a status indicator of N represents a non-covered service.  We looked at the file and Medicare rules. The provider billed a preventive medicine evaluation with procedure code 99287. This code has a status indicator of N and is non-covered by Medicare. Therefore, we decided that the Plan does not have to pay for the preventive medicine evaluation rendered on September 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you cannot stand up, walk, or take care of yourself. You say that you cannot go home alone, as you have no assistance. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing services or daily skilled therapy services.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The records do support that the enrollee requires skilled therapy services. However, the skilled therapy services are not needed on a daily basis. The enrollee does not require services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part-time basis appear appropriate in this case.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical pathology rendered on April 20, 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. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.      We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. 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 surgical pathology rendered on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gralise.  You asked the Plan to pre-approve Gralise. You say that the drug is medically necessary. The Plan denied your request. The Plan says Gralise is a self-administered drug.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.     The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gralise.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient lab testing provided on June 8, 2021, by an OON provider.  You asked the Plan to pay for outpatient lab testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee must see in-network providers.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient lab testing provided on June 8, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on August 29, 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on August 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for magnetic resonance imaging (MRI) of the spinal canal and contents (72141) rendered on July 23, 2021.  You asked the Plan to reduce the copayment for magnetic resonance imaging (MRI) of the spinal canal and contents. You say that prior to this procedure, you had confirmed the copayment amount with the Plan, as well as with the hospital. You also say that the agreed upon copayment amount was $150. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient hospital advanced imaging services.    You have been asked to pay a $250 copayment for magnetic resonance imaging (MRI) of the spinal canal and contents. A magnetic resonance imaging (MRI) of the spinal canal and contents falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for magnetic resonance imaging (MRI) of the spinal canal and contents (72141) rendered on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided from June 11, 2020, to June 18, 2020.  You asked the Plan to pay for the services provided. You say that the medical record supports the principal diagnosis. The Plan denied your request. The Plan says the services were reported with the incorrect DRG.  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 N17.9 defined as acute kidney failure, unspecified. 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 provided. Our physician reviewer found that the enrollee presented to the emergency room after been having found down at home for an unknown period of time. In this case, this enrollee did not experience anuria or oliguria, or a minimal change in creatinine by at least 1.5-fold from baseline or from the creatinine level measured following optimal hydration to the lowest value attained during the hospitalization. The review has determined that  the records did not show the billed diagnosis was supported in the medical records.   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 hospital services provided from June 11, 2020, to June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for pathology services provided on May 19, 2021.  You asked the Plan to waive the coinsurance for the pathology services. You say that the services should be covered as they are too expensive and necessary. The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a 50% coinsurance for pathology services (the total allowed amount is $112.42 x 50% = $56.21). The record confirms that these services were rendered out-if-network. Pathology services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category.   This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for pathology services provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breathing capacity test rendered on April 30, 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 separately payable.  The Plan must follow Medicare rules. The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used.  The provider submitted a claim for procedure codes 94010 (breathing capacity test) and 94060 (evaluation of wheezing). Code 94010 is a column II code with a modifier indicator of 0 when billed with column I code 94060. Code 94010 is not separately payable. Therefore, we decided that the Plan does not have to pay for the breathing capacity test rendered on April 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound care services provided on August 26, 2021.  You asked the Plan to pay for wound care. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the enrollee had elected hospice which was in effect on the date the services at issue were rendered.  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 17, 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 wound care services provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an electrocardiogram (93042) provided on May 8, 2021.  You asked the Plan to pay for an electrocardiogram. You say that this was billed appropriately. The Plan denied your request. The Plan says this is not separately 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, we have confirmed that code 93042 is a column II code to column I code 99291. 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 an electrocardiogram (93042) provided on May 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on December 30, 2020 by an out-of-network (OON) provider.  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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 the drug testing provided on December 30, 2020 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided on May 23, 2020, through June 21, 2020.  You asked the Plan to pay for the home health services. You say that you would like reconsideration because the documentation submitted supports the services billed. The Plan denied your request. The Plan says based on the primary diagnosis of Type 2 diabetes mellitus with chronic kidney disease, further skilled nursing care is unable to be validated as clinically appropriate.  The Plan follows Medicare rules. Medicare rules say that information from the patient's home health record must document the rationale that demonstrates that there is a reasonable potential for a future complication or acute episode and, therefore, may justify the need for continued skilled observation and assessment beyond the 3-week period.  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 home health services. Our reviewer says that the diagnosis does not justify the ongoing home health skilled nursing services being provided. Our physician reviewer found the enrollee is noted to have type II, non-insulin dependent, diabetes mellitus.  This diagnosis is chronic and will require lifetime management.  There is no evidence that the enrollee has had significant changes in her diabetes, multiple or frequent medication adjustments, or the addition of insulin to her treatment regimen.  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 home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided on May 23, 2020, through June 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for set-up portable x-ray equipment (Q0092) transportation of portable X-ray equipment and personnel (R0070) radiologic examination, foot (73630)  You asked the Plan to pay for the portable x-ray services. You say that you are requesting reconsideration of the claim and approval of a one time waiver to pay benefits at the network level. The Plan denied your request. The Plan says the claim was correctly processed and was applied towards the deductible. The enrollee has only met $335.08 of the $750 deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible.  The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the portable x-ray services was received on September 20, 2021. Therefore, we decided that the Plan does not have to pay for set-up portable x-ray equipment (Q0092) transportation of portable X-ray equipment and personnel (R0070) radiologic examination, foot (73630)
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the upper endoscopy with biopsy (43239) provided on August 30, 2021.  You asked the Plan to waive the copayment for the upper endoscopy. You say that you do not understand why you owe $350 for this service. 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 $350 copayment for outpatient surgery services.    You have been asked to pay a $350 copayment for the upper endoscopy. The upper endoscopy is classified as a surgical procedure and falls within the outpatient surgery 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 waive the copayment for the upper endoscopy with biopsy (43239) provided on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the rhythm electrocardiogram (EKG) rendered on May 18, 2021.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 93042 (rhythm EKG, 1-3 leads) and 93010 (routine EKG with at least 12 leads, interpretation, and report). Code 93042 is a column II code with a modifier indicator of 1 when billed with column I code 93010. Code 93042 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pre-approve the rhythm electrocardiogram (EKG) rendered on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on August 25, 2021.  You asked the Plan to pay for the dental cleaning. You say that your dental provider told you that it was necessary to have more frequent dental cleanings because you have medical issues which make regular dental hygiene difficult. The Plan denied your request. The Plan says your dental benefit covers a maximum of two standard adult dental cleanings per year. You had previous cleanings on January 11, 2021, and June 1, 2021, which were covered by the Plan. Therefore, the cleaning on the date in question exceeds the frequency limitation of your 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. The Plan can cover two standard adult dental cleanings (D1110) per plan year.    Though the Plan offers a dental benefit in excess of Medicare coverage, the cleaning is requested in a frequency that exceeds what is covered under this benefit. Documentation shows you had two previous cleanings covered in 2021. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on August 25, 2021.