Persius/hicric huggingface dataset:
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely provided in an alternate and low intensity setting such as in home with therapies.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the stress breaker (D6940) and comprehensive oral evaluation (D0150) provided on July 3, 2021.  

You asked the Plan to pay for the stress breaker and comprehensive oral evaluation. You say that you had not had dental work completed in five years. You also say that you were in terrible pain and are worried about your health due to a previous stroke. The Plan denied your request. The Plan says the stress breaker is not covered under the Plan. The Plan also says that the comprehensive oral evaluation exceeds the maximum allowed per 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, stress breaker (D6940) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on May 17, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the stress breaker (D6940) and comprehensive oral evaluation (D0150) provided on July 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on August 25, 2021.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  

The 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 70544 (MRA head) and 70551 (magnetic resonance imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. 

Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided from April 10, 2021, to June 10, 2021.  

You asked the Plan to pay for continuous glucose monitor supplies. You say that this is supported in the records. The Plan denied your request. The Plan says the records do not show that the criteria for coverage have been met.  

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan within the previous 6 months. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided from April 10, 2021, to June 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) services coded as 74177 and billed with the XE modifier provided on July 31, 2021.  You asked the Plan to pay for the CT services as billed. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the medical documentation does not support this code 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.  In this case, the CPT Code Manual definition of code 74177 is computed tomography, abdomen and pelvis; with contrast material(s).  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 CT services as billed. Our reviewer says that the documentation does not support the code as billed. Our reviewer found the medical records provided do not meet criteria for appending a modifier XE; therefore, there is no separate reimbursement for 74177 XE.   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 CT services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) services coded as 74177 and billed with the XE modifier provided on July 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pre-approve adult mental health outpatient services.  

You asked the Plan to pre-approve adult mental health outpatient services. You say that the requested services are a necessity for your care. The Plan denied your request. The Plan says that rules for coverage for the requested services have not been met.  

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. In this case, the Plan has not provided a valid reason to deny out-of-network coverage for the requested services. PPO plans must provide reimbursement for all Plan-covered medically necessary services received from non-contracted providers without prior authorization requirements. It is the burden of the Health Plan to substantiate their denial. Since the Plan's denial has not been substantiated, we must find in your favor. Therefore, we decided that the Plan has to pre-approve adult mental health outpatient services.   

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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tooth extraction (D7210) and a panoramic radiographic image (D0330) provided on August 10, 2021.  You asked the Plan to pay for a tooth extraction and a panoramic radiographic image. You say that you had an appointment with your dentist to have a crown re-cemented, but your dentist said it was fractured and the tooth had to be extracted. The provider made an appointment with another dentist and you did not know you would not be covered. The Plan denied your request. The Plan says you received dental services from a provider who chose not to receive Medicare funds. The provider is on a Medicare Opt-out list.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.     The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. We have confirmed that the provider opted out of Medicare on May 18, 2016. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210) and a panoramic radiographic image (D0330) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953) provided on August 26, 2021.  You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. The Plan denied your request. The Plan says these services are not covered benefits under the enrollee's 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 guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953) provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on September 9, 2021, to September 12, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you only stayed an extra day because you did not have a walker. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $195 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.in-network/inpatient care.   You have been asked to pay a $195 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $585 ($195 x 3 days = $585). The correct copayment has been applied to the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care.in-network/inpatient care 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 an inpatient hospital stay provided by a participating provider on September 9, 2021, to September 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services.  You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance company is directly behind your house and you feel the charges should be reduced or waived. The Plan denied your request. The Plan says you were charged this cost sharing 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 $350 copayment for each ambulance trip. You had one (1) ambulance trip. The Plan charged you $350 for these services. 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 ambulance services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87481, 87798, 88305, 88312, 88313) rendered by the OON provider on June 15, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services (87481, 87798, 88305, 88312, 88313) rendered by the OON provider on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 31, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. 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.  The file shows that CPT code 70450 was billed along with code 70496. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim information provided does not show that the code at issue was 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 computed tomography (CT) scan provided on July 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a knee replacement surgery provided on July 19, 2021. We also decided that the Plan does not have to waive the copayment for physical and occupational therapy (PT/OT) provided from July 19, 2021, to July 20, 2021.  You asked the Plan to waive the copayment for the surgery and PT/OT. You say that you feel that the copayment is too much as you are on a limited income. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each outpatient surgery at an outpatient hospital facility.   Your contract with the Plan also clearly says that you must pay a $35 copayment for each in-person specialist visit.  The file shows that the Plan has adjusted the copayment applied for the physical and occupational therapy services, lowering the amount from $82.80 to the correct amount of $35. You have been asked to pay a $225 copayment for the knee replacement surgery. The surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay a $35 copayment for the physical and occupational therapy services. Physical and occupational therapy falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The total for your services is $260. 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 knee replacement surgery provided on July 19, 2021. We also decided that the Plan does not have to waive the copayment for physical and occupational therapy (PT/OT) provided from July 19, 2021, to July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray services (71046) provided on July 31, 2021.  You asked the Plan to pay for the X-ray services. You say that you would like this claim reprocessed based on medical documentation. The Plan denied your request. The Plan says the documentation does not support an additional unit of billed code 71046 beyond what has already been paid.  The Plan must follow Medicare rules. Medicare rules say that claims lines that have been determined to be exact duplicates of another claim or claim line are denied.   We looked at the file and Medicare rules. In this case, the documentation does not support payment for an additional unit of 71046 beyond what has already been approved. Based on this information, we decided that Medicare rules for coverage of the X-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray services (71046) provided on July 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the motorized scooter (K0800).  You asked the Plan to pre-approve the motorized scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 motorized scooter. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not support that you have a mobility deficit that impairs MRADLs in the home and this mobility limitation is not ameliorated by a walker, cane, manual wheelchair. While you may have the cognition to safely operate the power scooter, the documentation does not reveal a home assessment to support that the requested device will be able to safely maneuver in the home and access rooms for MRADL participation.  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 motorized scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve the motorized scooter (K0800).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the general health panel rendered on February 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 the services are not covered.  The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code.  You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the respiratory panel rendered on July 26, 2021.  You asked the Plan to pay for you disagree with the denial.. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 87631 is not supported.  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 87631 is respiratory virus panel, 3-5 targets.  We find that CPT code 87631 is not supported in the medical record. Specifically, the records show that more than five targets were tested and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of you disagree with the denial. have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on July 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on January 20, 2021.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when the 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 a physical therapy assistant (PTA) 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 physical therapy services have not been met. Specifically, the billing provider is a physician assistant, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on January 20, 2021.