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

We decided that the Plan does not have to pay for the services (99223) provided on February 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not
support this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation
and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor
or unit".
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99223 is
not supported by the records provided. Our reviewer found that the documentation dated February 16, 2021,
does not include a comprehensive history, and does not support medical decision-making of high complexity.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (99223) provided on February 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization and aortography procedures provided on
June 24, 2021.
You asked the Plan to pay for revascularization and aortography. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the records do not support the codes billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 37221 revascularization, endovascular, open or
percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty
within the same vessel, when performed. The CPT Code Manual definition of code 75625 is aortography,
abdominal, by serialography, radiological supervision and interpretation.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for revascularization and aortography. Our reviewer says that
these codes do not meet the criteria for payment. Our reviewer found the medical records provided does not
include sufficient documentation to validate that 37221-50 was performed on June 24, 2021, therefore this
service cannot be verified. Code 75625 does not meet criteria for separate reimbursement. Per the National
Correct Coding Initiative Policy Manual, "Vascular embolization procedures include associated radiological
supervision and interpretation, intra-procedural guidance, road-mapping, and imaging necessary to document
completion of the procedure." and " Physicians shall not report radiologic supervision and interpretation codes,
radiologic guidance codes, or other radiology codes where the radiologic procedure is integral to another
procedure being performed at the same patient encounter." Therefore, 75625 is not eligible for separate
reimbursement.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of revascularization and aortography have not been met. Therefore, we decided
that the Plan does not have to pay for revascularization and aortography procedures provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on September 8, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that you feel the x-ray should be covered because you had a toothache. The Plan denied your request. The Plan says this procedure is covered twice in a 12-month period.

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. The contract says that bitewing x-rays are covered twice in any calendar year, and full mouth x-rays are covered once every 36 months. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to apply the in-network cost sharing to inpatient hospital services rendered from
March 31, 2021, to April 7, 2021.

You asked the Plan to apply the in-network cost sharing to inpatient hospital services. You say that your heart
began to malfunction, and you were unconscious nearly the whole time. You also say you were not aware of
any in-network or out-of-network issues. You also say the provider is expecting you to pay nearly your entire
check every month until the bills are paid off. The Plan denied your request. The Plan says that you were
charged the correct cost sharing amount.

The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of
immediate medical attention would result in serious jeopardy to their health.

We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with
an average knowledge of medicine would reasonably expect the absence of immediate medical care to
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to apply the in-network
cost sharing to inpatient hospital services rendered from March 31, 2021, to April 7, 2021.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services rendered on March 11, 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 procedure code A0422 is not covered.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.

We looked at the file and Medicare rules. Billed procedure code A0422 (ambulance [als or bls] oxygen and
oxygen supplies, life sustaining situation) has a status indicator of X and is statutorily excluded from Medicare.
Therefore, we decided that the Plan does not have to pay for the ambulance services rendered on March 11,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on
April 1, 2021.
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you disagree with
the charges because the biopsy did not bring a diagnosis and you cannot afford the charges. The Plan denied
your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $290
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $290 copayment for a fine needle aspiration biopsy. A fine needle aspiration
biopsy falls within the outpatient surgery including services provided at hospital outpatient facilities and
ambulatory surgical centers 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 a fine needle aspiration biopsy provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 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. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. 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 81295 (MSH2 full genetic sequencing), 81298 (MSH6 full genetic sequencing), and 81432 (hereditary breast cancer-related panel). Codes 81295 and 81298 are column II codes with a modifier indicator of 1 when billed with column I code 81432. The column II codes were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two endodontic therapies (D3310 x2) provided on
November 4, 2020.
You asked the Plan to pay for the endodontic therapies. You say that you would like to be reimbursed for these
services. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you
did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 two
endodontic therapies (D3310 x2) provided on November 4, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 8, 2021
by an out-of-network (OON) provider.
You asked the Plan to pay for a limited oral evaluation. You say that your previous dentist did not do a
satisfactory job and that is the reason why you had to seek dental services from a different provider. The Plan
denied your request. The Plan says the services are covered but you have exceeded frequency limits set in your
benefit Plan.
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 limited oral
evaluation once per calendar year.
We looked at the file and Medicare rules. The records show that you received a limited oral evaluation on
January 4, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this
information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met.
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July
8, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation services provided on March 26, 2021.

You asked the Plan to pay for the services provided. 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 the therapy treatment services at issue were not billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation services provided on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) provided on July 1, 2021.

You asked the Plan to pay for the incision and drainage of abscess. You say that the provider's office advised that this service would be covered. You also say that the office confirmed they were told half of this service would be covered. The Plan denied your request. The Plan says this procedure is not a covered benefit under the dental plan. The Plan also says that when you contacted the Plan on July 12, 2021, you were informed that the incision and drainage of abscess is not a covered service, and that extractions are covered at 50%.

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 incision and drainage of abscess (D7510) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you
received from April 1, 2021, to April 22, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you believe there should be no
copayment. You said that the enrollee was scheduled to leave the SNF on April 6, 2021, but he fell, requiring
him to stay longer. The Plan denied your request. The Plan says this cost sharing was charged correctly. Please
note that the enrollee only had $1840 remaining on his out-of-pocket maximum, so that is all that he is being
charged even though the copayment is technically more than that.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment for days 1-20, and a $184 copayment per day for days 41-100 for skilled nursing
facility care.
Records show that the enrollee was in the SNF from March 15, 2021, to April 22, 2021, for a total of 38 days.
The enrollee was not charged a copayment for the first 20 days in accordance with the Evidence of Coverage.
The enrollee was charged a $184 copayment per day for the remaining 18 days, for a total of $3312. However,
since the enrollee only had $1840 remaining on his out-of-pocket maximum for the year, his cost sharing was
limited to this amount. This means that the enrollee has been asked to pay the correct amount based on the
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in
the Plan. This cost sharing applies regardless of the reason for the length of the stay. Therefore, we decided that
the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from
April 1, 2021, to April 22, 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 the SNF services. You say that progression is being delayed. You say that you are legally blind and live by yourself. You say that you have no assistance and are subject to another fall. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and her lungs were clear. The enrollee received physical therapy. By the dates in question, the enrollee was at an independent to contact guard assist level for functional mobility, including gait to 300 feet with no assistive device. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture
(D0380) and consultation (D9310) provided on July 1, 2021.
You asked the Plan to pay for the cone beam CT image capture and consultation. You say that you would like
this claim to be reprocessed for payment. The Plan denied your request. The Plan says these services are not
covered benefits under your dental plan.
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 cone
beam computed tomography (CT) image capture (D0380) and consultation (D9310) provided on July 1, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT scan of the cervical spine (72125) provided on March 27, 2021.
You asked the Plan to pay for a CT scan of the cervical spine. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says that the services at issue were provided
for screening purposes only and therefore are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The medical records provided confirm that the CT scan at issue was not done for
screening purposes. The records show that the services were provided to evaluate the enrollee for a fall and an
inguinal hernia. Neither of these are screening purposes. The Plan's denial rationale has not been substantiated
by the case record. Therefore, we decided that the Plan has to pay for a CT scan of the cervical spine (72125)
provided on March 27, 2021.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76981) provided June 16, 2021.
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 76981 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, the CPT code billed has a Professional Component / Technical Component indicator of 1. The
service was rendered in the outpatient setting. The code was not billed with the required 26 modifier. Based on
this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore,
we decided that the Plan does not have to pay for an ultrasound (76981) provided June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 19, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting.
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not
have to pay for the lab services provided on February 19, 2021.