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

 We decided that the Plan does not have to pay for inpatient psychiatric services provided from August 18, 2021, through August 19, 2021.  You asked the Plan to pay for inpatient psychiatric services. You say that you have an outstanding balance and do not want to receive any further bills. The Plan denied your request. The Plan says a corrected claim was never received from this provider for reprocessing after multiple attempts from the Plan to obtain a corrected claim therefore, this claim remains upheld.   The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. The provider has not submitted, to the Plan, sufficient information to determine whether payment is due. The provider is not allowed to bill you for these services. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric services provided from August 18, 2021, through August 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (64566).  You asked the Plan to pre-approve posterior tibial nerve stimulation. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the service at issue is not medically necessary.  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 posterior tibial nerve stimulation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found posterior tibial nerve stimulation is considered a third line treatment option that is utilized when primary and secondary treatments have failed. Your stress urinary incontinence and urge incontinence have not been treated with standard first line treatments.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of posterior tibial nerve stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (64566).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical nutrition services provided on June 22, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services do not meet Medicare criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.   We looked at the file and the rules. The records do not show that the enrollee suffers from renal disease or diabetes. Based on this information, we decided the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical nutrition services provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on April 30, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. The records do not indicate that the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomographic angiography (CTA) scan of the chest (71275) provided on June 4, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the CTA scan services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 the computed tomographic angiography (CTA) scan of the chest (71275) provided on June 4, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental services (20900, 21248) to be covered under the medical benefit.  You asked the Plan to pre-approve dental services. You say that the enrollee broke tooth #8 as the result of an accident. These services have been requested under both the medical benefit and the dental benefit (using codes D7210, D6010 and D7953). These services are necessary and should be covered by one or the other. The Plan denied your request. The Plan says that although these services are necessary following an accident, they are dental in nature and cannot be covered by the enrollee's medical benefit. A separate review is being conducted to evaluate these services under the enrollee's dental benefit.  Medicare generally does not cover dental services. Treatment has been requested to remove and replace a broken tooth. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of teeth or the structures directly supporting the teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services (20900, 21248) to be covered under the medical benefit.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 1, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes are included in the dialysis rate. The Plan denied your request. The Plan says the tests are not separately reportable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.   We looked at the file and the rules. The records show that the enrollee was being treated for ESRD. The file shows that treatment included the labs at issue in this case. Labs should bill the facility directly for lab services as they are considered part of the composite rate.  No other payment for these services is allowed. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on July 28, 2021.  You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not include a signed physician order for this testing.  The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.   We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 28, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve magnetic resonance imaging, any joint of upper extremity (73221).  You asked the Plan to pre-approve the MRI. You say that you are requesting a review of this claim for MRI approval to the right shoulder. The Plan denied your request. The Plan says that the records do not support the requested service is medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   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 MRI. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee had a fractured humerus in July 2021and follow up imaging demonstrates healing. The record indicates that the enrollee has ongoing pain and there is a concern for impingement syndrome. The record indicates that the enrollee has pain despite physical therapy in November 2021.  The requested service is medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time.   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 MRI have not been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging, any joint of upper extremity (73221).   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xgeva, docetaxel, gemcitabine, nivolumab, dexamethasone, and triptorelin depot.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic prostate cancer. The Food and Drug Administration has not stated that the requested drug regimen is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's clinical situation. The requested drugs are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva, docetaxel, gemcitabine, nivolumab, dexamethasone, and triptorelin depot.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided on April 27, 2021.  You asked the Plan to pay for the services provided. You say that the medical records clarify the reason for treatment. The Plan denied your request. The Plan says the documentation failed to meet the requirements.  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: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  We find that CPT code 99223 is not supported in the medical record. The medical records do not indicate high complexity decision making was provided. There is no indication of how much time was spent with the enrollee. There is a more comprehensive code that describes the services provided to the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) provided on August 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you would like reconsideration because you were told that authorization was not required for the office visit. The Plan denied your request. The Plan says this service was not urgent, emergent or approved in advance.  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 the office visit (99214) provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve twelve (12) water-based physical therapy visits.  You asked the Plan to pre-approve twelve (12) water-based physical therapy visits. The Plan denied your request. The Plan says the documentation received fails to indicate the member cannot perform land-based exercises effectively to treat their condition without first undergoing the water-based therapy, or water-based therapy facilitates progression to land-based exercise or increased function. Therefore, medical necessity criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 twelve (12) water-based physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of the limited available records, you do not meet Medicare's coverage criteria for the requested twelve (12) aqua therapy visits. There are no clinical details of a physician's note or a diagnosis to support the medical necessity for the therapy. No prescription details are provided. The documentation does not show progress with land-based therapy and no documentation to support the transition from land to water-based therapy. The documentation does not support coverage for the requested therapy visits. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twelve (12) water-based physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) water-based physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 31, 2021.
You asked the Plan to pay for the services provided. You say that the service was medically necessary. The
Plan denied your request. The Plan says the service does not meet coding standards.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. The file shows that the enrollee received an office visit, in which
osteopathic manipulative treatment was provided. The records do not show that a separately identifiable
evaluation and management service was provided and is therefore not separately reportable. Based on this
information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit provided on August 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography coded 77065 provided on June
7, 2021.
You asked the Plan to pay for the diagnostic mammography. 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 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 77065
is a column II code to column I code 19083. 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 diagnostic mammography coded 77065 provided on June 7,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425) provided on May 12, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied
your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare
covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, nonemergency
transport (A0428, A0425) provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on May 30, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that any services related to the coronavirus would be fully covered. 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 20% coinsurance for DME and related supplies.   You received DME and related supplies on May 30, 2021. The record shows that the DME and related supplies do not qualify for a waiver. Therefore, you are responsible to pay your share of the cost-sharing charges. You are being asked to pay $17.81, which is less than the 20% coinsurance amount.   You have been asked to pay the total coinsurance amount of $17.81 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on May 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot inserts purchased on September 30, 2021.
You asked the Plan to pay for the foot inserts. You say that the item should be covered. The Plan denied your
request. The Plan says you obtained this item through a provider that is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the foot inserts purchased on September
30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an EKG provided on March 17, 2021.  You asked the Plan to waive the copayment for an EKG. You say that you disagree with the charges because you should owe a $0 for primary care physicians services and wellness exams. 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 $30 copayment for EKG's.  You received an EKG on March 17, 2021. EKG's are not included in annual wellness exams nor in primary care physician visits and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $12.04, which is less than the $30 copayment.   You have been asked to pay $12.04 for an EKG. An EKG falls 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 an EKG provided on March 17, 2021.