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

We decided that the Plan does not have to pay for the lab services provided on June 17, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code. 

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
code. Per Medicare rules, the testing should be reported with one unit of one CPT code.
 
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 the lab services provided on June 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) provided on August 9, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $285 copayment for Ambulance services. You have been asked to pay a $285 copayment for ambulance transportation. Ambulance transportation 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 ambulance transportation services (A0427) provided on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on September 14, 2021.

You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has 
not been billed with an appropriate modifier as required by Medicare rules.

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 70450 
is a column II code to column I code 70496. 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 computed tomography (CT) scan of the head or brain (70450) 
provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July
17, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the member should not
have a copay. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $345 copay each day one through five for inpatient hospital care.
The enrollee has been asked to pay a $345 copay each day one through five for the inpatient hospital care. This
service] falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive
the copayment for the inpatient hospital care provided on July 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on October 3, 2021
.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you started feeling 
pain and pressure in your chest and you checked your blood pressure, and it was high. You say you also felt 
dizzy, as if you were going to pass out and you had a headache and body aches. You say that the paramedics 
arrived, examined you, and told you that your heart was fine, and they offered to take you to the emergency 
room, but you opted to be taken by your daughter the next day. The Plan denied your request. The Plan says the 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. 

The ambulance company did not provide transport services on October 3, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the selective catheter placement, arterial system; each first 
order abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT code 36245) provided 
to the enrollee on May 19, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Our records indicate a National 
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 36247 and 36245. This 
PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, 
an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does 
not have to pay for the selective catheter placement, arterial system; each first order abdominal, pelvic, or 
lower extremity artery branch, within a vascular family (CPT code 36245) provided to the enrollee on May 19, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the
enrollee on April 2, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the documentation does not support a significant, separately identifiable evaluation and
management service to support the use of the -25 modifier.
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 99291 is Critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes."
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 says that the services at issue in
this case were not supported by the medical records. Our reviewer found the documentation does not include a
critical care evaluation and management service. The documentation describes provider assistance called to
intensive care unit (ICU) for respiratory distress, and decision was made to intubate.
The documentation does not support a separate evaluation and management service distinct from the intubation
provided, and therefore cannot be verified.
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 critical care services (procedure code 99291) provided to the enrollee on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit with wound
debridement(99324, 11042) provided on July 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for domiciliary or rest home visit with wound debridement. You say that the
treatment rendered to the patient was medically necessary per the physician that provided the services. You
also say that you have provided supporting records. The Plan denied your request. The Plan says these services
were not authorized, and all services provided to the member must be authorized.
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 domiciliary or rest home visit with wound
debridement(99324, 11042) provided on July 21, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided July 22, 2021, to July 27, 2021.

You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that you 
were dissatisfied with your care and don't feel you should owe a copayment. The Plan denied your request. The 
Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $298 
copayment per day, days 1 to 7 for inpatient hospital care.

You have been asked to pay a total of $1,192 ($298 copayment x 4 days = $1,192) for the inpatient hospital 
admission and services. The inpatient hospital admission and services fall within the Inpatient hospital 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 inpatient hospital admission 
and services provided July 22, 2021, to July 27, 2021.

Your complaint about concerns with the network provider not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an echocardiogram provided on September 13, 2021.  

You asked the Plan to waive the copayment for an echocardiogram. You say that you were told the price would be lower than what was billed. The Plan denied your request. The Plan says the proper copayment was applied.  

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 $200 copayment for diagnostic procedures and tests. The allowed amount was $159.68 which is lower than the copayment of $200. Therefore, the $159.68 was charged as the copayment for this service.    

You have been asked to pay a $159.68 copayment for echocardiogram. echocardiogram 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 echocardiogram provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the dialysis services provided from August 2, 2021, to August 31,
2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the
number of days/units exceeds the acceptable maximum.
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.
We looked at the file and the rules. The Plan has not provided Medicare rules or coding guidelines regarding
maximum units allowed. The Plan has not made reasonable and diligent efforts to gather and forward to us
information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for
the dialysis services provided from August 2, 2021, to August 31, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from January 22, 2022,
forward.
You asked the Plan to pre-approve SNF care. You say that the enrollee was put into the facility on December
24, 2021, and was put in Coronavirus (COVID) quarantine for about one (1) to two (2) weeks. You state they
developed COVID and was put in the COVID ward on January 15, 2022, and they were not able to get the
therapy the enrollee requires. The Plan denied your request. The Plan says the stay is not medically necessary
based on SNF criteria.
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 at the time of admission, the enrollee required
skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled
nursing needs. As of January 22, 2022, the enrollee did not require any skilled nursing or rehabilitation services
on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and predictable
period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living
(ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As
a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care
as of January 22, 2022. The enrollee did not have any parental medications, complex wound care or nutrition
given via a feeding tube. The enrollee received skilled care and improved; however, their functional
improvement had plateaued by January 22, 2022, and you did not require any further inpatient skilled
rehabilitation services. The enrollee's function was at or near their prior level of function and they could be
discharged to a lower level of care for further services. As of January 22, 2022, the enrollee required custodial
services. The denial for further inpatient skilled care is upheld.
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 continuation of SNF care from January 22, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia services (D9222 and D9223) provided on February 21, 2021.
  
You asked the Plan to pay for the deep sedation/general anesthesia services. You say that this was not a simple tooth extraction, and the dentist required the anesthesia. The Plan denied your request. The Plan says that anesthesia for dental procedures is not a covered benefit included under your health plan.
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case
.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesia services (D9222 and D9223) provided on February 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on October 6, 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 70450
is a column II code to column I code 70496. 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 (70450) provided on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GenVisc 850.

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 arthritis of the knee. 
The records do not include radiographic evidence of osteoarthritis. There is no documentation of failure of 
conservative non-pharmacological therapy. The Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. The GenVisc 850 is 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 GenVisc 850.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ondansetron, Dexamethasone Sodium Phosphate, Famotidine,
Bevacizumab, Paclitaxel, and Diphenhydramine.
You asked the Plan to pre-approve the requested drugs. You say that this treatment is medically necessary. The
Plan denied your request. The Plan says that these services are not medically necessary and not covered under
the Plan.
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 the requested drugs. Our reviewer says
that Ondansetron, Dexamethasone Sodium Phosphate, Famotidine, Bevacizumab, Paclitaxel, and
Diphenhydramine are medically necessary in this case. Our physician reviewer found there is FDA approval
for these drugs for treatment of the enrollee's condition in patients who received no more than 2 prior
chemotherapy regimens.
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 requested drugs have been met. Therefore, we decided that the Plan has to
pre-approve Ondansetron, Dexamethasone Sodium Phosphate, Famotidine, Bevacizumab, Paclitaxel, and
Diphenhydramine.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from May 21,
2020, through May 29, 2020.
You asked the Plan to pay for inpatient hospital care. You say that they submitted supporting documentation
for reconsideration. The Plan denied your request. The Plan says there is a change in DRG from 091 to 092 due
to removal of the codes for unspecified severe protein-calorie malnutrition (E43) and adult body mass index
[BMI] 24.0-24.9 (Z68.24).
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 unspecified severe protein-calorie malnutrition
(E43). 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 inpatient hospital care. physician reviewer
found the review has determined that the diagnosis code is not supported by the medical records. The DRG
adjustment is justified.
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 to the enrollee from May 21, 2020, through May 29, 2020.