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

We decided that the Plan does not have to pre-approve inpatient psychiatric services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no medical issues that require treatment at this level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 services. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found it is not expected
that this enrollee would improve in a reasonable period of time for the dates in question, as the enrollee does not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self. The health plan's denial of continued inpatient psychiatric services is appropriate. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services for the enrollee.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93880) provided on March 26, 2021.
You asked the Plan to pay for a duplex scan. You say that this is supported in the records. The Plan denied your request. The Plan says this is 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 93880 is a column II code to column I code 76536. 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 a duplex scan (93880) provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is an in-network provider within a reasonable distance that is available.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage rendered on April 9, 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. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 2. You billed 264 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage rendered on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on April 20, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The records show that more than 5 targets were testing this case. Per L37315, Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Euflexxa
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230), protective restoration (D2940), amalgam (D2150), and resin based composite (D2392) provided from April 14, 2021, to June 7, 2021.
You asked the Plan to pay for the dental services. You say that you cannot believe that a dental plan does not cover getting fillings done. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says that protective restoration is not listed as a covered service. The Plan says that fillings are not listed as covered services either.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230), protective restoration (D2940), amalgam (D2150), and resin based composite (D2392) provided from April 14, 2021, to June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) for tooth #3.
You asked the Plan to pre-approve the crown (D2740). You say that the tooth is weak and fragile and needs a crown. You say that the tooth will break and will probably need to be extracted if a crown is not placed. The Plan denied your request. The Plan says a crown is only covered once per tooth every 60 months.
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, there is also a maximum benefit of one crown per tooth every 60 months. The Plan paid for the crown (D2740) for tooth #3 provided on September 7, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) for tooth #3
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative monitoring rendered on February 23, 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 G0453 (continuous intraoperative neuromonitoring) and 95955 (electroenchephalogram during surgery). Code G0453 is a column II code with a modifier indicator of 1 when billed with column I code 95955. Code G0453 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 continuous intraoperative monitoring rendered on February 23, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular study 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 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 93976 (duplex scan of arterial inflow) and 76705 (abdominal ultrasound).
Code 93976 is a column II code with a modifier indicator of 1 when billed with column I code 76705. Code 93976 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 vascular study rendered on July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 6, 2020 to November 16, 2020.
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 records do not support the billing of DRG 682 and diagnosis code N17.9.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 682 (renal failure with MCC) and diagnosis code N17.9 (acute kidney failure, 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 these services. We looked 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 rendered from November 6, 2020 to November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and does not require transfer to a LTACH.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.  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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays and ultrasounds provided on
March 3, 2021.
You asked the Plan to waive the copayments for X-rays and ultrasounds. You say that you do not know if the
claims were processed correctly and would like it to be looked into. 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 $50
copayment for each X-ray and a $160 copayment for ultrasounds.
You received two X-rays on March 3, 2021. Therefore, you are responsible to pay a $50 copayment per each
X-ray. However, you are only being asked to pay the allowed amount of $63.52, which is less than the total
copayment amount.
You received an ultrasound on March 3, 2021. Therefore, you are responsible to pay the allowed amount of
$110.4, which is less than the $160 copayment.
The total amount you owe is: $173.99.
You have been asked to pay the total copayment amount of $173.99 for X-rays and ultrasounds. X-rays and
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 copayments for X-rays and ultrasounds provided on March 3, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 21, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87661, 87086, 87801, 87481, 87491, 87496, 87529, 87532, 87556, 87563, 87591, 87640, 87651, 87653, 87798) provided on July 23, 2021.  You asked the Plan to pay for laboratory services. You say that this should be considered in-network because the specimen was sent to the laboratory by the ordering physician. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87661, 87086, 87801, 87481, 87491, 87496, 87529, 87532, 87556, 87563, 87591, 87640, 87651, 87653, 87798) provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care rendered on January 17, 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 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
30-74 minutes of critical care spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care rendered on January 17, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided August 13, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says these services were non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment panels.
We looked at the file and Medicare rules. The tests at issue are non-covered under Medicare rules. 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 lab services provided August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81225, 81223, 81227, & 81226) provided June 28, 2021.
You asked the Plan to pay for the lab services. 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 codes 81225, 81223, 81227, & 81226 are not supported in the medical record. Specifically, the claim was submitted with multiple unbundled codes for a single panel. 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 lab services (81225, 81223, 81227, & 81226) provided June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuplazid caplet 34mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuplazid caplet 34mg for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on May 24, 2021.
You asked the Plan to pay for SelectMDx testing. You say that this is recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx. SelectMDx is deemed investigational by the National Comprehensive Cancer Network (NCCN). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. The service at issue is considered not medically necessary and is therefore not covered. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on May 24, 2021