Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan, thorax, diagnostic; without contrast material (CPT code 71250), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says that they did not receive physical exam results that show a reason this study is needed, and the records did not include a detailed history that shows this study is needed.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer found the enrollee has chronic renal disease and the CT of July 29, 2021, showed new findings in the lungs compared to a prior scan of 10/20. It is reasonable to perform a surveillance CT to assess any further changes in this high-risk enrollee. A detailed physical exam at this point in time would not be a necessary precursor to the requested CT for follow-up abnormal findings from a prior exam. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan, thorax, diagnostic; without contrast material (CPT code 71250), for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gradient compression wrap (CPT code A6545).
You asked the Plan to pre-approve the gradient compression wrap. You say that this is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 gradient compression wrap have not been met. Review of the file shows that you do not currently have an ulcer; therefore, you do not meet the Medicare criteria for the gradient compression wrap. Therefore, we decided that the Plan does not have to pre-approve the gradient compression wrap (CPT code A6545).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CTA, abdomen, with contrast material(s), including non-contrast
images, if performed, and image postprocessing (CPT code 74175), for the enrollee.
You asked the Plan to pre-approve the CTA. You say that the guidelines outline that the service is only
supported every six (6) months for an aneurysm. You state the last CTA performed for the enrollee was in
September 2020, which was over twelve (12) months ago. The Plan denied your request. The Plan says that the
enrollee's records do not show results of prior picture studies such as x-ray or ultrasound that show a reason this
request is needed.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CTA. Our physician reviewer found
the enrollee has s a 5.2 cm ascending thoracic aortic aneurysm and is OVERDUE for their surveillance CTA.
Last exam was September 17, 2020, over fifteen (15) months ago.
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 CTA have been met. Therefore, we decided that the Plan has to pre-approve
CTA, abdomen, with contrast material(s), including non-contrast images, if performed, and image
postprocessing (CPT code 74175), for the enrollee.
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 the testing services rendered on April 15, 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 payment is included in the inpatient claim.
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective payment systems are payment in full for all inpatient hospital services. We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was under inpatient status. Payment for the services is included in the payment on the inpatient claim. Therefore, we decided that the Plan does not have to pay for the testing services rendered on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the stool analysis testing provided on May 7, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing does not meet the documentation requirements.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The records do not show that specific pathogen testing was ordered due to current signs and symptoms. The records do not show the results of the broad testing would be used in the management of a specific problem. It appears the testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the stool analysis testing provided on May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on July 20, 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 38792 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 38792 (injection procedure, radioactive tracer) and 38900
(intraoperative identification of sentinel lymph node[s]). Code 38792 is a column II code with a modifier
indicator of 1 when billed with column I code 38900. Code 38792 was not billed with an appropriate modifier
to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the injection
services rendered on July 20, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility services provided on August 1, 2020, through August 31, 2020 and billed with the Patient Driven Payment Model (PDPM) Codes KAGB1 x 18 days and KAGA0 x 13 days.
You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the nursing component of the PDPM Score has been reduced to the Clinically Complex Category as a Function Score of 14 or less is needed to support the Special Care High Category.
The Plan must follow Medicare rules. Medicare rules say that if the resident's PDPM Nursing Function Score is 15 or 16, he or she classifies as Clinically Complex. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility services have not been met. Specifically, the record does not show that the member had a Function Score of 14 or less to support the Special Care High Category. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility services provided on August 1, 2020, through August 31, 2020 and billed with the Patient Driven Payment Model (PDPM) Codes KAGB1 x 18 days and KAGA0 x 13 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency, routine transportation trips.
You asked the Plan to provide coverage for additional non-emergency, routine transportation trips. You say that you are legally blind and cannot walk well and you have fallen trying to get to the pharmacy. The Plan denied your request. The Plan says additional trips beyond 52 one-way trips are not a covered benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers 52 one-way trips each year. Additional trips beyond 52 are not a covered benefit. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergency, routine transportation trips
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for BRCA genetic testing provided on May 5, 2021.
You asked the Plan to pay for genetic testing. You say that you disagree with this denial and are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because the enrollee has no personal history of cancer so this is considered non-covered screening testing.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for BRCA genetic testing provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 4, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that your primary care physician was not available so you saw this physician instead. You feel that this visit should be considered a primary care provider visit and not a specialist visit. 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 $40 copayment for specialist visits. The record shows that you received services from a specialist on August 4, 2021. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit provided on August 4, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) brain (including brain stem) (70551).
You asked the Plan to pre-approve an MRI. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria and the requested service is not 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 an MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has memory loss. The enrollee had an MRI a year ago and the results are not available. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) brain (including brain stem) (70551).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on July 23, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study).
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that
the Plan does not have to pay for the abdominal ultrasound rendered on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740) for tooth #18.
You asked the Plan to pre-approve the crown. You say that tooth #18 has an extensive mesial occlusal filling, and the enrollee recently reported with an additional portion of the mesial of this tooth fractured. You also say that to just replace the filling on this tooth will leave very fragile lingual and buccal cusps. The Plan denied your request. The Plan says that the x-rays show a crown is not needed to fix the enrollee's tooth. The Plan also says that the tooth does not appear to have significant breakdown due to decay or trauma.
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 crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the documentation provided meets the criteria for coverage for a crown restoration (D2740) for tooth #18. Our physician reviewer found the enrollee's dental record and x-rays indicate the presence of a large defective restoration and the narrative indicates the presence of additional fracture making the remaining coronal structure weak. Our reviewer also found that that a crown restoration is medically reasonable and necessary to provide the enrollee with adequate masticatory function and to protect the weakened tooth from additional fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth #18.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 22, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 15271 and 15272 are 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 15271 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. The definition of code 15272 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). We find that CPT codes 15271 and 15272 are not supported in the medical record. Specifically, there is no documentation of application of a skin substitute graft to the trunk, arms, or legs for a total wound area of up to 100 sq cm, for the first 25 sq cm or less, to support code 15271.
There is no documentation of application of skin substitute graft to the trunk, arms, or legs for a total wound surface area of up to 100 sq cm, for each additional 25 sq cm, to support code 15272. 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 surgical services rendered on May 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (99212) provided on June 26, 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 service 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 a $35 copayment for each Medicare-covered urgent care visit. You have been asked to pay a $35 copayment for the Medicare-covered urgent care visit 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 urgent care visit (99212) provided on
June 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 28, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you only received an electrocardiogram and nothing else was done. 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 $90 copayment for emergency care. The record shows that you received emergency care on July 28, 2021. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (CPT code E0218).
You asked the Plan to pre-approve the item. You say that the ice machine is needed to decrease the swelling and not just for comfort. The Plan denied your request. The Plan says this item is not covered by Medicare or the health plan.
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 item have not been met. The rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (CPT code E0218).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on
July 13, 2021, and July 14, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you are receiving
separate statements for the setup and actual radiation treatment. You say that you received only received one
statement for the same treatment in 2020 and want to know why you are now receiving two statements. The
Plan denied your request. The Plan says the coinsurance 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 10%
coinsurance for each Medicare-covered radiation therapy service, $75 out-of-pocket maximum per day.
You have been asked to pay a total of $75.60 for the radiation therapy services.
Date of Service Service Allowed Amount Coinsurance Total
July 13, 2021 Radiation Therapy Services $580.40 10% $58.04
July 14, 2021 Radiation Therapy Services $175.59 10% $17.56
TOTAL: $75.60
The radiation therapy services 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 coinsurance for radiation therapy services
provided on July 13, 2021, and July 14, 2021.