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

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) coded 70544 provided on September 4, 2021.
You asked the Plan to pay for the MRA. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are 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 70544 is a column II code to column I code 70551. 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 the magnetic resonance angiography (MRA) coded 70544 provided on September 4, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on February 8,
2021.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 99233
and 36556.
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 99233
is a column II code to column I code 36556. 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 the subsequent hospital care (99233) provided on February 8,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system (PERS) (S5161).
You asked the Plan to pre-approve a personal emergency response system. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support that a PERS is medically necessary as there is no evidence that the enrollee is left home alone for long periods of time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 a personal emergency response system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee lives with her son and daughter. There was no provided evidence that the enrollee was living alone or would likely have high risk of incident that would require this service. The enrollee does not qualify for a personal emergency response system at this time, and therefore, this request for such will be considered not medically necessary based on the provided documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a personal emergency response system have not been met. Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system (PERS) (S5161).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on October 21, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate
payment is made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. 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 anesthesia services provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a glass crown (D2740) to be provided by a participating provider.
You asked the Plan to pre-approve a glass crown. You say that D2740 is medically necessary. The Plan denied
your request. The Plan says that this is not medically necessary.
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 glass crown
when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a glass crown. Our reviewer says that a
replacement crown is medically necessary. Our physician reviewer found the documentation provided shows
that the criteria for coverage for D2740 has been met.
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 glass crown have been met. Therefore, we decided that the Plan has to preapprove
a glass crown (D2740) to be provided by a participating provider.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from March 23, 2021, to June 1, 2021.
You asked the Plan to pay for the SNF stay. The Plan denied your request. The Plan says this request does not meet the criteria for a SNF admission.
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 pay for the SNF stay. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you did not have daily skilled nursing needs
that required the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found
that you did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment
of a skilled professional therapist. Our physician reviewer also found that you did not require daily skilled
nursing and/or skilled therapy on 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 stay have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) stay provided from March 23, 2021, to June 1, 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. The Plan denied your request. The Plan says you have exhausted your 100 SNF benefit days.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from July 1, 2021, through August 6, 2021; August 27, 2021, through August 30, 2021; September 2, 2021, through September 14, 2021; September 17, 2021, through October 8, 2021 and November 4, 2021, through November 30, 2021. The Plan has covered 100 days of SNF care. 

Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 2, 2021, to March 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $390 copayment per day for days 1-5 for Inpatient Hospital Care.
You have been asked to pay a $390 copayment for 5 days of inpatient hospital care ($390 x 5 = $1,950). The
plan has granted you a charitable discount of $1092.00 which leaves the total member liability at $858.00.
The plan verified with the provider that you have already made one day's copayment of $390.00 and that you
have a remaining balance of $468.00. 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 inpatient hospital
care provided from March 2, 2021, to March 9, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee has failed conservative approaches to treatment at this time. You state failed conservative treatment approaches include physical therapy, medications, injections and various non-sustainable treatments. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that they have chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has grade 2 anterolithesis severe spinal stenosis
L4-L5, the level requested for treatment and 15-20 degrees of scoliosis. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for computed tomography (CT) of the heart (75572) provided on March 22, 2021.  You asked the Plan to pay for the CT of the heart. You say that you would like reconsideration because the documentation supports that this service was medically necessary. The Plan denied your request. The Plan says that payment for this service is the responsibility of the facility to any vendor.  The Plan must follow Medicare rules. Medicare rules say that carriers must pay for the professional component (PC) of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT of the heart have been met. Specifically, the record shows that this service is the PC of the CT scan. The Plan is responsible for paying for the PC of radiology services. Therefore, we decided that the Plan has to pay for computed tomography (CT) of the heart (75572) provided on March 22, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on September 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 70450
is a column II code to column I code 70496. 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 the services (70450) provided on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a replacement crown (D2740) for tooth # 30.
You asked the Plan to pre-approve a replacement crown. You say that the perimeter of the crown has broken off. You say that food gets stuck between your teeth. You also say that this causes a great deal of pain while chewing. The Plan denied your request. The Plan says that the crown for tooth # 30 is not medically necessary.
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 replacement crown when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a replacement crown. Our reviewer says that the crown for tooth # 30 is not medically necessary. Our physician reviewer found the provided documentation indicates that there is no reasonable method of repairing the existing crown, and the food impaction issue will lead to caries on both # 30 and the adjacent tooth over time as well as possible periodontal damage. The reviewer found that replacement of the crown would be considered necessary as the crown is not serviceable in its current condition, the criteria has been met for replacement. 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 replacement crown have been met. Specifically, the file shows that the crown is not serviceable in its current condition. Therefore, we decided that the Plan has to pre-approve a replacement crown (D2740) for tooth # 30.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance charged for outpatient surgery provided from May 12, 2020 to May 13, 2020.

You asked the Plan to reduce this cost share. You say that you do not believe this cost share is correct as you thought this was inpatient care. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by the provider and the Plan contract agreement.

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 surgical services. This treatment was billed as outpatient surgery. 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 coinsurance charged for outpatient surgical services provided from May 12, 2020 to May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on May 13, 2021.

You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says in most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. Prior authorization must be obtained before seeking care.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision provider. 

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nervous system surgery (64999), surgical trays (A4550),
surgical supplies (A4649) and propofol injection (J2704) provided on September 29, 2021.
You asked the Plan to pay for the nervous system surgery (64999), surgical trays (A4550), surgical supplies
(A4649) and propofol injection (J2704). You say that the patient failed all prior conservative treatment, and
this was deemed medically necessary by the provider. You say that there is no question the services were
medically necessary, and the claim should be reprocessed for payment. The Plan denied your request. The Plan
says surgical code 64999 is in excluded from payment in an Ambulatory Surgical Center. The Plan also says
that the remaining codes are not 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.
We find that CPT code 64999, A4550, A4649 and J2704 are not supported in the medical record. Specifically,
per Addendum EE, CPT code 64999 is not payable in an ambulatory surgical center. The payment for CPT
codes A4550, A4649 and J2704 is packaged when services are rendered in an ambulatory surgical center.
Separate reimbursement is not made for these services Based on this information, we decided that Medicare
rules for coverage of the nervous system surgery (64999), surgical trays (A4550), surgical supplies (A4649)
and propofol injection (J2704) have not been met. Therefore, we decided that the Plan does not have to pay for
the nervous system surgery (64999), surgical trays (A4550), surgical supplies (A4649) and propofol injection
(J2704) provided on September 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound (76830) provided on September 29, 2021.
You asked the Plan to waive the copayment for the transvaginal ultrasound. You say that the services should be covered. The Plan denied your request. The Plan says only one copayment should have applied for both of the ultrasounds performed, they have partially overturned this case and upheld one copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.
You have been asked to pay a $122.98 copayment for a transvaginal ultrasound, which is less than the $160 copayment states in the Plan's contract. Transvaginal ultrasounds 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 copayment for a transvaginal ultrasound (76830) provided on September 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by a physical therapy assistant on May 3, 2021.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when 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 the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a physician assistant, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by a physical therapy assistant on May 3, 2021