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

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 8, 
2021.
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says this code is not separately payable with no modifier.
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial mandibular partial denture (D5212), and a complete maxillary denture (D5110) provided by a participating provider on August 5, 2021.
You asked the Plan to pay for a partial mandibular partial denture and a complete maxillary denture. You say that you feel like these services should be covered. The Plan denied your request. The Plan says the dentures that were provided are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial mandibular partial denture (D5212), and a complete maxillary denture (D5110) provided by a participating provider on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you require cardiac monitoring and other
medically necessary services that a SNF will not be able to accommodate. The Plan denied your request. The
Plan says the member does not meet Medicare criteria for coverage.
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 you are receiving appropriate care at the present acute care hospital. The requested
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and
able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), 2 additional periapical x-rays (D0230), and re-evaluation of limited oral evaluation (D0170) provided from September 27, 2021, to October 22, 2021.
You asked the Plan to pay for the dental services. You say that you never requested a re-evaluation. You say that you were advised there would be no charge for this service. You also say that these services should be covered. The Plan denied your request. The Plan says the services are not covered.
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 periapical x-rays and re-evaluation
of limited oral evaluation are not among those covered under this benefit. Therefore, we decided that the Plan
does not have to pay for the initial periapical x-ray (D0220), 2 additional periapical x-rays (D0230), and reevaluation
of limited oral evaluation (D0170) provided from September 27, 2021, to October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) for tooth 30.
You asked the Plan to pre-approve a crown for tooth 30. You say that you would like a crown covered. The Plan denied your request. The Plan says The submitted radiographs (x-rays) show that there is caries (dental decay) below the level of the supporting bone extending into the furcation area. Tooth #30 would be considered non-restorable.
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 crown for tooth 30 when the tooth does not have subosseous and/or furcation caries.
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 crown for tooth 30. Our reviewer says that a crown for tooth 30 does not meet the criteria for coverage. Our physician reviewer found that the documentation does not meet the criteria for coverage for a crown restoration (D2740) for tooth #30 due to poor prognosis due to excessive caries extending sub-osseous and into the furcation area. 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 crown for tooth 30 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) for tooth 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on October 5, 2021.
You asked the Plan to pay for the hearing aids. You say that these hearing aids were expensive, and you feel the Plan should cover part of this cost. The Plan denied your request. The Plan says hearing aids are only covered when they are purchased through the routine hearing vendor as specified in the contract. Hearing aids are only covered through this vendor and are not covered when purchased from other providers.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are the approved models purchased through the Plan's specified hearing vendor. We looked at the file and the Plan's rules. The provider in this case does not participate with the Plan's hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 15, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the appropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.
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. Specifically, this claim was submitted with the laboratory place of service code while the records suggest that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting
from July 28, 2021, to July 29, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you feel you are not responsible for this
cost share because you should not owe the cost for self-administered medications. The Plan denied your
request. The Plan says these drugs are not covered under your medical coverage. The Plan also says you can
ask for them to be covered by your prescription drug coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 pay for the self-administered drug
provided in an outpatient setting from July 28, 2021, to July 29, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99214) transthoracic
echocardiography (93306) routine electrocardiogram (93000) interrogation device evaluation (93261) to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the outpatient services. You say that you would like to continue seeing this
provider as this doctor is aware of your treatment needs. The Plan denied your request. The Plan says enrollee's
must receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the outpatient office visit (99214) transthoracic echocardiography (93306) routine electrocardiogram (93000)
interrogation device evaluation (93261) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MyoPro 2 myoelectric orthotic devices (L8702).  You asked the Plan to pre-approve the orthotic device. You say that given her history and inability to independently carry out her activities of daily living, the enrollee has been referred by her family practice physician for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.   We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro 2 myoelectric orthotic devices (L8702).
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 is transferring min assist and ambulating 100 feet with a walker min assist. She also has weakness and fatigue in therapy. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 23, 2021.
You asked the Plan to pay for procedure code 62320. You say that this service was billed correctly and should be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the Plan has requested medical records from you multiple times to show that these services were appropriate. To date, you have not provided these records. Without this documentation, neither the Plan nor our organization can determine the appropriateness of these services. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 23, 2021.
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 July 14, 2021, to July 19, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the DRG and secondary diagnosis are 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 DRG 562 (FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC). 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 clavicle fracture. From the information that was received, documentation was inconsistent regarding a diagnosis of toxic encephalopathy. Even though toxic metabolic encephalopathy was documented by neurologist, supporting clinical documentation was not found within the record. The documentation did not support a change in mental status beyond baseline and supported by neurological examination findings documented by provider. The review has determined that the DRG and secondary diagnosis were not supported in the medical records. The most appropriate DRG is DRG 563: FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC. 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 July 14, 2021, to July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L2397, L1851) provided on September 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a knee orthosis. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is a non-participating provider and pre-authorization was absent.
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 a knee orthosis (L2397, L1851) provided on September 15, 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 x-ray exam of the shoulder (73030) rendered by the out-of-network (OON) provider on October 5, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the shoulder (73030) rendered by the out-of-network (OON) provider on October 5, 2021.
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's current medical condition does not require intensive physician or
nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but
the documentation does not reveal that this therapy must be only on an intensive level 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 23, 2021, to January 28, 2021. You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the determination was to remove secondary diagnosis code J96.01 - acute respiratory failure with hypoxia.
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. 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 further evaluation and treatment of acute heart failure in a patient with underlying hypertension. A review of the documentation received was incomplete to reflect evidence of hypoxemia refractive to low flow supplemental oxygen in a patient with an acute exacerbation of heart failure and underlying coronary artery disease, abnormal arterial blood gas results consistent with acute respiratory failure, or noninvasive/invasive ventilatory assistance during the encounter to substantiate an additional diagnosis of acute respiratory failure with hypoxia. In this case, the documentation supported treatment of an acute exacerbation of heart failure with underlying coronary artery disease and was incomplete to reflect additional resource intense interventions and monitoring consistent with a life-threatening acute failure of the respiratory system. The review has determined that the claim was not billed with the correct DRG and diagnosis codes. 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 January 23, 2021, to January 28, 2021.