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

 We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235)  You asked the Plan to pre-approve an EGD. You say that you would like an EGD covered for the enrollee. The Plan denied your request. The Plan says the supporting records do not provide supporting information to support the use of the EGD procedure and the enrollee does not have the risk factors that would support the EGD procedure.  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 an EGD. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee was diagnosed with esophagitis and started on medication. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is not 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 an EGD have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235)
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on July 26, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on  July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulation (electro-acupuncture) device.  You asked the Plan to pre-approve electro-acupuncture device. You say that the enrollee is an excellent candidate for treatment with this device. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because auricular stimulation is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that use of electro-acupuncture devices is not covered by Medicare.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulation (electro-acupuncture) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a queen orthopedic mattress.  You asked the Plan to pre-approve a queen orthopedic mattress. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.  The Plan must follow Medicare rules. Medicare rules say that mattresses are covered only where hospital bed is medically necessary.  We looked at the file and Medicare rules. Review of the file does not support that a hospital bed was ordered. Without a hospital bed, the mattress is non-covered. Based on this information, we decided that Medicare rules for coverage of a queen orthopedic mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a queen orthopedic mattress.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for an office visit (90471, 90715) provided May 7, 2021.  You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says that this service was not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan denial notice did not articulate why the service was denied. The plan did not provide the criteria or Medicare coverage rules used to make the determination. Therefore, we decided that the Plan has to pay for an office visit (90471, 90715) provided May 7, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for testing services provided to the enrollee on March 2, 2021 and billed under code 52352-59.  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 code 52352-59 is included in the payment of code 52356; therefore, it cannot be separately reimbursed. The documents received do not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. The  National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 52281 and 52356. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair.  The Plan must follow Medicare rules. Medicare requires claims to be submitted with the appropriate codes.  In this case, we have confirmed that code 52352-59 is not separately billable for Medicare claims.  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 testing services provided to the enrollee on March 2, 2021 and billed under code 52352-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a carbon monoxide sensor (RAD 57 machine).  You asked the Plan to pre-approve carbon monoxide sensor. You say that you need this equipment to find out when to go outside and adjust. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this item is not primarily medical in nature and is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a carbon monoxide sensor (RAD 57 machine).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health services provided from June 3, 2021, to June 17, 2021.  You asked the Plan to pay for outpatient mental health services. You say that the provider told you that she has always opted out of Medicare, but previous claims were paid. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not enrolled in Medicare and is not payable.  The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered services, a provider must be enrolled in the Medicare program.   We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided from June 3, 2021, to June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cardiology consult to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the out-of-network cardiology consult. You say that the out-of-network provider is able to provide a higher level of service. The Plan denied your request. The Plan says there are network providers 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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network cardiology consult. Our reviewer says that the services can be provided by network providers. Our physician reviewer found there are credentialed cardiothoracic surgeons within the patient's network who are experienced in the treatment of single vessel coronary disease.   In summary, there is insufficient documentation to support the medical necessity for referral to an out-of-network provider for the patient's cardiac treatment.  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 out-of-network cardiology consult have not been met.   The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the out-of-network cardiology consult. Therefore, we decided that the Plan does not have to pre-approve a cardiology consult to be provided by an out-of-network (OON) provider.
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 IRF will be the best option for this enrollee, and a skilled nursing facility will not provide the necessary care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can appropriately receive therapy at a lower level of care.

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 that 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and pulp vitality test (D0460), provided on July 6, 2021.  You asked the Plan to pay for the limited oral evaluation and pulp vitality test. You say that the services should be covered. The Plan denied your request. The Plan says the pulp vitality test is not a covered benefit and you have exhausted your benefits for limited oral evaluation.  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 limited oral evaluation (D0140), and pulp vitality test (D0460), provided on July 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient, which requires these 3 key components (CPT code 99285-25) provided to the enrollee on April 13, 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 supported by the records.

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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer found the records do not justify the CPT code.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient, which requires these 3 key components (CPT code 99285-25) provided to the enrollee on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on July 22, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that the provider is in-network and it was a second opinion. The Plan denied your request. The Plan says problem focused limited oral evaluation is not a covered expense under your dental plan. The Plan also says that your benefits for the first intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.  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, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on June 10, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on July 22, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from April 15, 2021, to April 21, 2021.  You asked the Plan to pay for the SNF care. You say that on the day you were to be discharged, you developed Shingles. You say that the facility would not let you leave due to being contagious. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says that your authorization for SNF care ended on April 15, 2021, as a Notice of Medicare Non-Coverage was signed. The Plan says also says that the benefit was applied correctly.  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. Specifically, we find that there were no medical records provided to support the Plan's decision of no payment. Without medical records, we cannot determine if there were skilled services provided on the dates of service in this case. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from April 15, 2021, to April 21, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 14, 2021.  You asked the Plan to waive the copayment for the ambulance transport. You say that you never wanted to take the ambulance, but the provider insisted. 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 $445 copayment for each one-way trip by ground ambulance.   You have been asked to pay a $445 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services 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 ambulance transport provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 82140, 83036, 84443, 85025) and the travel allowance one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on August 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 laboratory services (36415, 80053, 82140, 83036, 84443, 85025) and the travel allowance one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for specialist visits received from May 27, 2021, to June 25, 2021.  You asked the Plan to waive the coinsurance for specialist visits. You say that you have paid for many hospital and doctor's appointments this year, which should have covered all of your out-of-pocket expenses. You believe the claim should have been paid. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan further explains that at the time the claim for June 25, 2021, was processed, you had only paid $1,968.53 toward your out-of-pocket expenses. However, the Plan reports that your deductible had previously been met, thus, the Plan will pay a portion of costs for covered services.   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 20% coinsurance for Medicare Part B Prescription Drugs and Physician/Practitioner Services, including specialist office visits. Your contract with the Plan also clearly says that you must pay $3,290 toward your maximum out-of-pocket amount, before the Plan will cover 100% of the costs.  You have been asked to pay a 20% coinsurance for specialist visits, with a total cost-share of $1,238.36. Specialist visits falls within the Physician/Practitioner Services, including doctor's office visits benefit category. The record shows that during these specialist visits, you also received joint injections which fall within the Medicare Part B Prescription Drugs benefit category. The record also indicates you had not met your maximum out-of-pocket expenses at the time of service, which means you are responsible for your cost-share. See below for a breakdown of total costs.  Date of Service May 25, 2021: Allowed Amount $5,420.98 ? 20% = $1,084.20 Date of Service June 4, 2021: Allowed Amount $92.04 ? 20% = $18.41 Date of Service June 11, 2021: Allowed Amount $172.65 ? 20% = $34.53 Date of Service June 18, 2021: Allowed Amount $92.04 ? 20% = $18.41 Date of Service June 25, 2021: Allowed Amount $414.03 ? 20% = $82.81 Total Charges: $1,238.36  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 coinsurance for specialist visits received from May 27, 2021, to June 25, 2021.