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

We decided that the Plan does not have to pay forindividual psychotherapy session services (90837) provided March 2, 2020.You asked the Plan to pay forthe psychotherapy services. You say that your records do not reflect a payment. Please send copy of payment info.The Plan denied your request. The Plan says this service is a duplicate as this has been already processed and paid.The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider whois eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. Based on the documentation provided, it appears that the plan previously paid for the appealed services. The records show that these services were paid on check dated March 10, 2020.Therefore, we decided that the Plan does not have to pay forindividual psychotherapy session services (90837) provided March 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the copayment  foroutpatient  mental  health  care provided  on May 26, 2020.You asked the  Plan to waive  the copayment  foroutpatient  mental health  care. You say that you  were  not informed  that  you  would  owe a copayment  and cannot  afford  the charges.The  Plan  denied  your  request.  The Plan  says the  claims  were processed  correctly  and  you  are being  charged  the  correct amount.The  rules  saya 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  outpatient  mental  health  care. You  have  been asked to pay a $40 copayment  for  outpatient  mental  health  care. Outpatient  mental  health  care falls  within  the  outpatient  mental  health  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 foroutpatient  mental  health  care provided  on May 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forcritical  care services  provided  on November  24, 2019.You asked the  Plan to pay  forcritical  care services.  You say  that the Plan  should  pay this  claim.The  Plan denied  your  request.  The  Plan  says the  documentation  does not  include  the time  spent  providing  this  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, the  CPT Code Manual  definition  of code 99291is  evaluation  and management  of the  critically  ill or critically  injured  patient,  first  30-74 minutes. The  CPT Code Manual  definition  of code 99292 is critical care, each additional  30 minutes)  is  used to report  additional  block(s)  of  time,  of up to 30 minutes  each  beyond the  first  hour.We find  that  CPT code 99291, 99292 is not  supported  in  the  medical  record. Specifically, critical  care is  a time-based service  and the physician's  progress notes do not document  the total time for the services. Based on this  information,  we decided  that  Medicare  rules  for coverage  of critical  care services  have  not  been met.Therefore,  we decided  that  the Plan  does not have to pay forcritical  care services  provided  on November  24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transurethral destruction of prostate tissue; by
radiofrequency generated water vapor thermotherapy (REZUM).
You asked the Plan to pre-approve Transurethral destruction of prostate tissue; by radiofrequency generated
water vapor thermotherapy (REZUM). You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that REZUM is only covered for certain indications.
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 Transurethral destruction of prostate
tissue; by radiofrequency generated water vapor thermotherapy (REZUM). Our reviewer says that the
documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee has benign prostatic hyperplasia and lower urinary tract symptoms.
Treatment with tamsulosin and finasteride has not been effective. Prostate specific antigen is 1.92 ng/mL.
Prostate size is 50 cc. Maximum urinary flow rate is 12 mL/s. The documentation does not support that the
enrollee is a poor candidate for other surgical interventions for BPH (e.g., cardiac disease, pulmonary disease,
etc.), or at high risk of bleeding. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Transurethral destruction of prostate tissue; by radiofrequency generated water
vapor thermotherapy (REZUM) have not been met. Therefore, we decided that the Plan does not have to preapprove
Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
(REZUM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206), the application of desensitizing resin (D9911 x 2), a crown (D2740), and core build up (D2950).
You asked the Plan to pre-approve fluoride varnish, desensitizing resin, the crown, and core build up. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the crown and core build up are not necessary as the documentation that was received was not labeled. The Plan says fluoride varnish is not listed as a covered service. The Plan says the application of desensitizing resin is not listed as a covered service either.
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 fluoride varnish, desensitizing resin, the crown, and core build up 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 fluoride varnish, desensitizing resin, the crown, and core build up. Our reviewer says that the requested crown and core build up are not medically necessary. Our physician reviewer found the provided documentation does not show that the tooth has
sufficient structural damage that the tooth would need to gain strength from a full coverage restoration. The reviewer found that a core buildup is only necessary where there is insufficient retention if a crown is to be placed, and this is not applicable in this case. Therefore, the reviewer found that the crown and core build up for tooth # 2 are not medically reasonable and necessary. 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 fluoride varnish, desensitizing resin, the crown, and core build up have not been met. Therefore, we decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206), the application of desensitizing resin (D9911 x 2), a crown (D2740), and core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forthe  transcutaneous  electrical  nerve  stimulation  (TENS) device  provided  on April  16, 2020.You asked the  Plan to pay  forthe  TENS device.  You say  that the enrollee  needs this  device  for  severe  back pain. The Plan  denied  your  request.  The  Plansays TENS devices  are not covered  for back pain.The  Plan  must  follow  Medicare  rules.  Medicare  rules  say  that  items  and  services  that  are not medically necessary  are not covered.We looked  at the  file  and Medicare  rules. The  record does not show  the  enrollee  is  in  an approved clinical study. Based on this  information,  we decided  that  Medicare  rules  for coverage  of the  TENS device  have  not been met.Therefore,  we decided  that  the Plan  does not  have to pay forthe  transcutaneous  electrical  nerve stimulation  (TENS)  device  provided  on April  16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mixed respiratory virus panel rendered on March 25, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that procedure code 87633 (mixed respiratory virus panel, 12-25) is used whenmore limited panels would not be medically appropriate.We looked at the file and Medicare rules. The file shows that the mixed respiratory virus panel billed with code 87633 was not the most medically-appropriate testing. 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 forthe mixed respiratory virus panel rendered on March 25, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forshoulder arthroscopy procedures include extensive debridement (29823) subacromial decompression (29826) provided May 7, 2020.You asked the Plan to pay forthe surgical procedure. You say that you have attached medical records that support codes 29823 and 29826. Please review and reprocess for payment.The Plan denied your request. The Plan says the records do not support the service 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.We find that CPT code  is not supported in the medical record. Specifically, the operative report did not include documentation to meet the guidelines of a surgical shoulder arthroscopy, with extensive debridement. The operative report did not include documentation to meet the guidelines of a surgical shoulder arthroscopy, with decompression of subacromial space with a partial acromioplasty, with or without coracoacromial ligament (arch) release (listed separately in addition to code for primary procedure). Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met.Therefore, we decided that the Plan does not have to pay forshoulder arthroscopy procedures include extensive debridement (29823) subacromial decompression (29826) provided May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the detailed and extensive oral evaluation (D0160), amalgam - one surface, primary or permanent (D2140), and full mouth debridement (D4355)
You asked the Plan to pre-approve the detailed and extensive oral evaluation, amalgam - one surface, primary or permanent, and full mouth debridement. You say that these services are medically necessary. The Plan denied your request. The Plan says the member's benefits have been exhausted.
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 detailed and extensive oral evaluation, amalgam - one surface, primary or permanent, and full mouth debridement when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the detailed and extensive oral evaluation, amalgam - one surface, primary or permanent, and full mouth debridement have not been met. Specifically, the oral evaluation and mouth debridement are only covered once every 6 months and the plan indicates that a previous treatment was completed within six months. Further, the Plan indicate that the maximum benefit allowed of $750 has been met and no further payment is available. Therefore, we decided that the Plan does not have to pre-approve the detailed and extensive oral evaluation (D0160), amalgam - one surface, primary or permanent (D2140), and full mouth debridement (D4355)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on July 16, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forneuromuscular  stimulator,  electronic  shock  unit  (E0745).You asked the  Plan to pay  forthe  neuromuscular  stimulator.  You say  that as per received  correspondence found  that  claim  is  pending  for  medical  records, therefore,  attached  medical  notes  for  review.  Please  review and reprocess  the bills.The  Plan  denied  your  request.  The  Plan  says this  device  including  supplies  is  not a Medicare  covered  benefit  with  the  available  information. 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 pay  for the  neuromuscular  stimulator.  Our reviewer says  that  the requested  items/services  are not considered  medically  reasonable  and necessary  in  this  case. Our physician  reviewer  found  The  notes describe  muscle  weakness  but  do not specify  an etiology.  The  device ordered is  not a TENS unit  for  pain  but  rather  a neurostimulator.  There  is  no indication  clearly  identified  for this  unit.  It is not  medically  reasonable  or 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 the  neuromuscular  stimulator  have  not  been met.Therefore,  we decided that  the Plan  does not have to pay forneuromuscular  stimulator,  electronic  shock unit  (E0745)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation rendered on May 3, 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 the services are not payable.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. The provider billed procedure code 85060 with POS code 22 for an outpatient hospital. The services were not performed in an inpatient setting; therefore, the physician interpretation is not separately payable. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation rendered on May 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 22, 2019.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation facility setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gradient Compression Sleeve and ready-to-wear
Gauntlet Compression Device identified with codes E1399 and A6549.
You asked the Plan to pre-approve a Gradient Compression Sleeve and ready-to-wear Gauntlet Compression
Device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the requested items are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by codes E1399 and
A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a Gradient
Compression Sleeve and ready-to-wear Gauntlet Compression Device identified with codes E1399 and A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care (93308) provided on May 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 has network providers available who can provide the items/servicesat 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 forsubsequent nursing facility care (93308) provided on May 27, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lipid panel and thyroid stimulatinghormone (TSH) testing rendered on July 22, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not supported.The Plan must follow Medicare rules. Medicare rules say that lipid panels and TSH testing are covered when specific criteria are met.We looked at the file and Medicare rules. There are no records to support that the services meet the Medicare criteria for coverage. 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 forthe lipid panel and thyroid stimulating hormone (TSH) testing rendered on July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 20, 2019.
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 81227-90, 81230-90, 81231-90, 81328-90, 81401-90, and 81479-90 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. We find that CPT codes 81227-90, 81230-90, 81231-90, 81328-90, 81401-90, and 81479-90 are not supported in the medical record. Specifically, there are no submitted lab results for the billed date of service. 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 laboratory services rendered on November 20, 2019.