Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve deep sedation/general anesthesia (D9222, D9223), the surgical
placement of an implant (D6010) and second stage implant surgery (D6011) for tooth #10.

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that these services are not covered by the Plan's dental 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 offers a $1,000
comprehensive annual allowance to be used toward any dental service.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have been met. Specifically, the Plan's contract clearly states that the $1,000
allowance for comprehensive dental care may be used for any service and is not restricted to those listed in the
contract. The Plan has also indicated that at the time of the review, the enrollee still had funds left in this annual
allowance amount. Therefore, we decided that the Plan has to pre-approve deep sedation/general anesthesia
(D9222, D9223), the surgical placement of an implant (D6010) and second stage implant surgery (D6011) for
tooth #10.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit you had on March 5, 2019, and the inpatient hospital stays you had from December 15, 2020, to December 18, 2020, and December 20, 2020, to December 23, 2020.

You asked the Plan to waive the copayments for the ER visit and the two inpatient hospital stays. You say that you cannot afford these bills. The Plan denied your request. The Plan says you were charged these copayments 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 $75 copayment for emergency room visits and a $95 copayment per day for days 1-5 for each inpatient hospital admission.

You have been asked to pay a $75 copayment for the ER visit and a $95 copayment per day for each of the two inpatient hospital stays. You were in the hospital for three days for each hospital stay, for a total of $285 per admission ($95 x 3 = $285). This means that you have been asked to pay the correct amounts 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 copayments for the emergency room (ER) visit you had on March 5, 2019, and the inpatient hospital stays you had from December 15, 2020, to December 18, 2020, and December 20, 2020, to December 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging you received on June 4, 2021.

You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were not told that the copayment for this service would be $300. You believe that the authorization notice should have advised what the copayment would be. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment for diagnostic imaging, including myocardial nuclear perfusion imaging. 

You have been asked to pay a $300 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the diagnostic imaging 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 myocardial perfusion imaging you received on June 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging you had on June 9, 2021.

You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that this is a high cost for a stress test and you are on a fixed income. The Plan denied your request. The Plan says this copayment was charged 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 $250 copayment for diagnostic radiology services, including nuclear cardiac imaging. 

You have been asked to pay a $250 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the diagnostic radiology 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 myocardial perfusion imaging you had on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammogram provided on May 10, 2021.
You asked the Plan to pay for the imaging services. You say that the appropriate modifier is on procedure 77065. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. We find that CPT code 77067 was billed with procedure code 77065. Billed services may be justifiable for this code combination. However, the claim provided does not indicate an appropriate modifier was billed for the code pair. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic mammogram provided on May 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on April 2, 2021.

You asked the Plan to pay for an eye exam. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an eye exam provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper and lower denture (D5110 and D5120) provided on May 28, 2021.
You asked the Plan to pay for the complete upper and lower denture (D5110 and D5120). You say that the office did not let you know if they checked your dental coverage. You say that you would not have opted for the set of dentures if you were informed before the service was rendered. The Plan denied your request. The Plan says the services are not covered 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 complete upper and lower denture (D5110 and D5120) provided on May 28, 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 the enrollee will have a better chance of
being discharged home. The Plan denied your request. The Plan says the LTACH would add no additional
services.
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 physician
reviewer found that in this case, the enrollee was admitted to the acute care hospital with esophageal-pleural
fistula and gastrointestinal bleeding. The record indicates that the enrollee has had a prolonged and complicated
hospital course and is still being weaned. The enrollee continues to receive acute care services, and these have
not been denied. The medical record does not indicate that the enrollee requires services that she is not
currently receiving but that would be available at the LTACH facility.
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 gingival irrigation (D4921) provided on May 27, 2021.

You asked the Plan to pay for the gingival irrigation (D4921). You say that they never advised you this was not covered. You say that you are on a fixed income and cannot afford this. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case
.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on March 10, 2021.
You asked the Plan to pay for the therapeutic activities (97530). You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.
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 97530 has a bundled relationship with code 92526 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 is a 78-year-old male with a past medical history of coronary artery disease and chronic kidney disease who presented to the acute hospital on October 7, 2021, with renal insufficiency and heart failure. While you do require skilled therapy services, there is no documentation that the patient requires skilled nursing services. In this case, skilled services are not required on a daily basis. In conclusion, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services provided on July 20, 2020.

You asked the Plan to pay for the services provided. You say that the medical records support medical
necessity. The Plan denied your request. The Plan says the services are part of a primary procedure.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.

In this case, the CPT Code Manual definition of code 93313 is echocardiography, transesophageal, real-time
with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe
only.

We looked at the file and the rules. We find that CPT code 93313 is not supported in the medical record. The
medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59
modifier have not been met. Therefore, we decided that the Plan does not have to pay for the echocardiography
services provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on April 14, 2021.
You asked the Plan to pay for the dental service. You say that you paid $185 for the extraction. You say that your dental coverage did not cover any of it. The Plan denied your request. The Plan says the extraction is not listed as a covered service.
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 extraction (D7210) provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99153) provided on March 1, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has denied correctly in this case.

The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. 

We looked at the file and Medicare rules. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from October 12, 2020, to October 16, 2020.

You asked the Plan to pay for the services provided. You say that the claim was billed appropriately. The Plan denied your request. The Plan says supporting medical records is incomplete regarding the diagnosis of unspecified cerebral infarction

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 a secondary diagnosis code, I63.9, defined as cerebral infarction, 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 documentation did not include evidence of frequent neuro checks, documentation of the stroke scale score, or discussion regarding tPA, (tissue plasminogen activator) administration. Brain imaging did not support an acute cerebral infarction. Clear evidence of focal ischemic injury based on symptoms persisting beyond 24 hours was not present. The discharge summary did not indicate a plan for stroke rehabilitation. The review has determined that the records did not show that the diagnosis of cerebral infarction diagnosis was clearly documented and had reasonable support through the clinical data and treatment. 

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 October 12, 2020, to October 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hand surgery you had on June 16, 2021.
You asked the Plan to waive the coinsurance for the hand surgery. You say that you were not aware that this surgery would cost this much. You said that had you known the cost, you would have thought more about it and saved up for it. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for outpatient surgery. You have been asked to pay 20% coinsurance for the hand surgery. The hand surgery falls within the outpatient surgery 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 the outpatient hand surgery you had on June 16, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on June 15, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications.
We looked at the file and the rules. The records show that the enrollee is has non-small cell lung cancer. She is being treated with Tagrisso. The records do not show that tissue-based comprehensive genomic profile (CGP) testing was infeasible. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed and sales tax received on April 27, 2021.
You asked the Plan to pay for the hospital bed and sales tax. You say that you required this equipment. The Plan denied your request. The Plan says the items received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the hospital bed and sales tax received on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of lower extremity arteries or arterial bypass grafts.

You asked the Plan to pay for the diagnostic service. You say that this was performed as a precaution as the enrollee has a strong family history of aneurism rupture including an uncle with leg artery aneurism. The Plan denied your request. The Plan says Per NCD guidelines, the primary diagnosis code Z8249 does not meet medical necessity for procedure code 93926.

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 Medicare rules. The diagnosis Z8249 is not listed on the LCD as an ICD-10 code that supports medical necessity. The test at issue in this appeal was requested solely for screening purposes. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of lower extremity arteries or arterial bypass grafts.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from June 18, 2020, through July 31, 2020.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says custodial services are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services provided from June 18, 2020, through July 31, 2020.