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

 We decided that the Plan does not have to pre-approve an inpatient admission.  

You asked the Plan to pre-approve the inpatient admission. The Plan denied your request. The Plan says the inpatient hospital admission is not medically necessary.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.    

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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this case. Our physician reviewer found based on the presentation and initial workup, you require only short-term supervision, fluids. Our reviewer found that workup was negative for an acute condition which would warrant a prolonged hospital course. Our physician reviewer also found that based on the initial workup and response to treatment, it is not expected that you would require hospital services that would likely cross 2 midnights.  

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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided August 11, 2021.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that you don't feel that you were properly informed about the frequency limit for this type of x-ray. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the complete series of intraoral x-rays once every three years.   We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of x-rays was previously covered on May 15, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the complete series of intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided August 11, 2021.   Your complaint about potentially receiving incomplete or misleading information from a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory services (80048, 83735, 84403, 85025, 82306, 84100) provided on July 20, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 $10 per day for other Medicare-covered laboratory tests that are not FIT tests.    You have been asked to pay $10 for the laboratory tests provided. 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 laboratory services (80048, 83735, 84403, 85025, 82306, 84100) provided on July 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued home health skilled care visits.  You asked the Plan to pre-approve home health care. You say that you still need services to care for your wounds. The Plan denied your request. The Plan says the denial of authorization for continued home health care is correct, because your current needs do not appear to be skilled in nature.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 home health care. Our reviewer says that you do not meet the Medicare criteria for continued home health skilled care. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are functioning at a level appropriate for a lower level of care. Ongoing home health skilled care is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health skilled care visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76098) provided November 20, 2020.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that 4 units of CPT code 76098 are not supported in the medical record. The medical record only supports 3 units of CPT code 76098. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76098) provided November 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra.  You asked the Plan to pre-approve Xiidra. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Xiidra.   Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel (R0070) provided on July 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the portable x-ray services. You say that the enrollee was at an assisted living facility at the time the x-rays were performed. Please reconsider the claims in question. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 radiologic examination, chest (71045) set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel (R0070) provided on July 7, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for set-up portable x-ray equipment (CPT code Q0092) and transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen (CPT code R0070) provided to the enrollee on May 20, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The provider did not bill as required by Medicare coding regulations. HCPCS code Q0092 is the set-up component and HCPCS code R0070 represents the transportation of the x-ray equipment to the patient. Per the above Medicare guidelines if the patient is in a covered Part A stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. Therefore, as the member is in a covered Part A stay and the billed POS is 31 and we find the Medicare rule for payment of HCPCS codes Q0092 (1 unit) and R0070 (1 unit) rendered May 20, 2021, has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider service for payment. Therefore, we decided that the Plan does not have to pay for set-up portable x-ray equipment (CPT code Q0092) and transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen (CPT code R0070) provided to the enrollee on May 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 27 units, 6.75 hours per day, of personal care services (T1019).

You asked the Plan to pre-approve additional hours of personal care services. You say that you would like to get your services back as soon as possible. You also say that you need the personal care services because your condition is getting worse. The Plan denied your request. The Plan says you do not meet State benefit guidelines for more hours per the State assessment tool.

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 additional hours of personal care services. Our reviewer says that the documentation does not support that the additional hours are needed to provide adequate support for you. Our physician reviewer found you are medically stable without any recent hospitalizations or medical complications. Our physician reviewer also found that the approved daily hours of 24 units, 6 hours per day, of personal care services (T1019) allows for appropriate support and care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional hours of personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve 27 units, 6.75 hours per day, of personal care services (T1019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on August 12, 2021, through August 14, 2021.  

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford your costshare. The Plan denied your request. The Plan says the cost share was applied 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 $275 copayment each day one through five for inpatient hospital care.   

You have been asked to pay a $275 copayment each day one through five for the inpatient hospital care. This service falls within the inpatient hospital 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 the inpatient hospital care provided on August 12, 2021, through August 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) provided during a trigger point injection procedure on March 15, 2021.  

You asked the Plan to pay for ultrasonic guidance for needle placement. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the procedure at issue is experimental/investigational.  

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 pay for ultrasonic guidance for needle placement. Our reviewer says that the service at issue is not considered medically reasonable and necessary in this case. Our physician reviewer found that there are no practice guidelines that support the use of ultrasound guidance for trigger point injections. The service at issue is considered experimental/investigational.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) provided during a trigger point injection procedure on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision (76376), the transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography (C8929), and the perflutren lipid microspheres injection (Q9957) rendered by the out-of-network (OON) provider on May 6, 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 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision (76376), the transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography (C8929), and the perflutren lipid microspheres injection (Q9957) rendered by the out-of-network (OON) provider on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received from June 16, 2021 to August 23, 2021.

You asked the Plan to pay for the services. You say that you want to receive a portion of your money back. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received from June 16, 2021 to August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation provided to the enrollee on January 21, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed with the appropriate primary code.

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 64636 is an add-on code and has not been billed with an appropriate primary procedure code. Additionally, this code was also billed with modifier -51, which is not appropriate as the multiple procedure indicator for this case is 0.

Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation provided to the enrollee on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the hospital discharge day management; 30 minutes or less (99238) provided May 9, 2021.

You asked the Plan to pay for the hospital discharge. You say that this service should be covered. The Plan denied your request. The Plan says that more than one hospital discharged was billed.

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 it appears the Plan has denied coverage of the hospital discharge due to a potential duplicate billing. The Plan's case file did not provide any documentation to support that a hospital discharge for the same hospital stay was already billed and covered. Therefore, we decided that the Plan has to pay for the hospital discharge day management; 30 minutes or less (99238) provided May 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on January 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 procedure code 99223 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 99223 is initial hospital care, per day, for the evaluation
and management of a patient, which requires these 3 key components.

We find that CPT code 99223 is not supported in the medical record. Specifically, the records document
hospital discharge services and not initial hospital care. 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 initial hospital care rendered on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on April 29, 2021.  You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that you spoke with the Plan and they advised the codes that the dentist put on the claim were not covered. You also say that you are not sure if you can do anything about this. The Plan denied your request. The Plan says this is not a covered service under your 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 localized delivery of antimicrobial agents (D4381) provided on April 29, 2021.