Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on May 11, 2021.  You asked the Plan to pay for the hospital outpatient clinic visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 G0463 is hospital outpatient clinic visit for assessment and management of a patient.  We find that CPT code G0463 is not supported in the medical record. Specifically, the claim was billed without the G0 condition code. The appropriate reporting of Condition Code G0 allows for accurate payment under Outpatient Prospective Payment System (OPPS) in this situation. Medicare guidelines for this code have not been met. Based on this information, we decided that Medicare rules for coverage of the hospital outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on May 11, 2021.
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. The Plan denied your request. The Plan says you do not need an
intensive therapy program with multiple visits from a rehab doctor.
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 physician reviewer found
that you were admitted to the acute care hospital for a deep vein thrombosis of the lower extremity. Your
medical problems are stable. While you have a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive rehabilitation program.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a GoGo scooter provided on June 14, 2021.  You asked the Plan to pay for a GoGo scooter. You say that the item at issue is a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a GoGo scooter provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0242U) provided May 13, 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 documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service listed on
the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (0242U) provided May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a replacement of a cranial neurostimulator (61885) provided
on April 14, 2021.
You asked the Plan to pay for a replacement of a cranial neurostimulator. You say that the services at issue
were a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the
services at issue have not been met.
The Plan follows Medicare rules. Medicare rules say that VNS is reasonable and necessary for patients with
medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has
failed.
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 a replacement of a cranial neurostimulator.
Our reviewer says that the services at issue are not medically reasonable and necessary in this case. Our
physician reviewer found that the information provided for review was limited to the procedure note. It cannot
be independently determined at this time that you had treatment-resistant epilepsy and were not a surgical
candidate or surgery had failed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a replacement of a cranial neurostimulator have not been met. Therefore, we
decided that the Plan does not have to pay for a replacement of a cranial neurostimulator (61885) provided on
April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88342) provided on May 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88342
is a column II code to column I code 88360. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the services (88342) provided on May 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99202) radiologic examination, spine,
lumbosacral (72100) radiologic examination, spine, cervical; two or three views (72040) provided July 9, 2021.
You asked the Plan to pay for the chiropractic services. You say that you had to obtain x-rays on your back due
to severe pain. Your doctors sent you to this provider to have them done so they could check the issue going
on. The Plan denied your request. The Plan says these services are not covered when rendered by a
chiropractor.
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 outpatient office visit (99202) radiologic examination, spine, lumbosacral
(72100) radiologic examination, spine, cervical; two or three views (72040) provided July 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back surgery to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve a back surgery to be provided by an OON provider. You say that the
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able
to provide these services. Therefore, coverage criteria have not been met.
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
a back surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the eye exam and refraction provided on June 17, 2021.
You asked the Plan to hold you harmless for the eye exam and refraction. You say that this was the only eye
exam you remember receiving in 2021. You say that you should be able to get one eye exam a year with a $0
copayment. The Plan denied your request. The Plan says that the claim processed correctly.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the eye exam and refraction by a contract provider. The file does not show that the Plan
provided notice that the eye exam and refraction would not be covered. Under Medicare rules, this means the
eye exam and refraction is considered approved by the Plan. Specifically, the record indicates that two claims
were billed for a routine eye exam and refractions. The documentation submitted does not include any medical
records to determine what services were rendered. Additionally, the member states they received one routine
eye exam. It is not reasonable to believe that the member was aware additional services were rendered.
Therefore, we decided that the Plan has to hold you harmless for the eye exam and refraction provided on June
17, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 7) provided on July 21, 2021.
You asked the Plan to pay for the dental services. You say that your insurance agent advised in late 2020 you
should get the services done, pay for them, and submit a copy of it to your insurance. You say that you were
not able to follow through with these services until the middle of the following year for health reasons. You
also say that you feel that something should be paid for these services. The Plan denied your request. The Plan
says extractions are not listed as covered services.
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 extractions are not among those
covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the extractions (D7140 x 7) provided on July 21,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the eye exam provided on August 17, 2021.  You asked the Plan to waive the copayment for the eye exam. You say that you had an eye exam and paid $40 but you aren't sure if you were supposed to pay. The Plan denied your request. The Plan says the copayment 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 $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.      You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision 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 eye exam provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473 x 2) provided on
February 2, 2021.
You asked the Plan to pay for the dental services. You say that your dentist advised these services were
necessary so that your denture will fit properly. The Plan denied your request. The Plan says removal of torus
mandibularis is not listed as a covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the removal of torus mandibularis is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
removal of torus mandibularis (D7473 x 2) provided on February 2,2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services submitted with DRG 871 provided
from January 16, 2020 to January 23, 2020.
You asked the Plan to pay for the inpatient services submitted with DRG 871. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
supported by the documentation.
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 A41.9 identified as sepsis, unspecified organism.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the inpatient services submitted with DRG
871. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found
during the inpatient hospital admission, the enrollee remained hemodynamically stable. There were no
documented signs of sustained hypotension or utilization of vasopressors. While enrollee presentation
warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction
due to a dysregulated host response to infection. There was no evidence of significant physiologic instability.
DRG 871 is not supported by the documentation. The principal diagnosis of A41.9 (Sepsis unspecified
organism) was not supported by the documentation.
We looked at this physician's review, 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 services submitted with DRG 871 provided from January 16, 2020 to January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve eating disorder residential treatment.
You asked the Plan to pre-approve eating disorder residential treatment. You say that the services are
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage
criteria has not been met.
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 eating disorder residential treatment.
Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a
composite score of 17-22. This correlates with treatment in a residential treatment. All told, the requested
residential treatment program services are medically necessary for the treatment of this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of eating disorder residential treatment have been met. Therefore, we decided that
the Plan has to pre-approve eating disorder residential treatment.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an
inpatient basis, at a SNF level of care as of December 13, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided March 1, 2019, to March 9,
2019.
You asked the Plan to pay for the inpatient hospital care. You say that DRG 871 was correctly billed. The Plan
denied your request. The Plan says DRG 871 is not supported in the records.
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 871. We asked our physician reviewer to
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in
denying the request to pay for the inpatient hospital care. Our reviewer says that DRG 871 is not supported.
Our physician reviewer found the records support alcohol pancreatitis (DRG 439). The records do not show
any evidence of sepsis.
We looked at this physician's review, 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 inpatient hospital care provided March 1, 2019, to March 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan
provided on June 23, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you were told to return six months
after your first CT scan and were under the impression that this scan would be covered in full as well. 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 $175
copayment for each advanced radiology service, including CT scans.
The record shows you had a low dose computed tomography (LDCT) scan on March 22, 2021, which is
covered once every 12 months. The CT scan you received on June 23, 2021 falls within that 12 month period.
Therefore, you have been asked to pay $140.55, which is less than the $175 copayment for a CT scan. CT
scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on
June 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided you do
not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term
care facility on a part time basis appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care