Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851x2) suspension sleeve (L2397x2) neuromuscular stimulator, electronic shock unit (E0745) and electrical stimulator supplies (A4595) provided October 29, 2020.
You asked the Plan to pay for the orthoses and neurostimulator and supplies. You say that the claim was denied as evidence of misrepresented services and insurance needs medical records to process the claim further. Please take into consideration and process the claim for further payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthoses provided. The Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and neurostimulator and supplies have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851x2) suspension sleeve (L2397x2) neuromuscular stimulator, electronic shock unit (E0745) and electrical stimulator supplies (A4595) provided October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Detect testing (procedure code 0012M) provided on November 3, 2020.

You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says the denial of payment for this test is correct, because this test is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that genetic testing code 0012M is not covered for date of service November 3, 2020. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder Detect testing (procedure code 0012M) provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral feeding supplies (B4035, B4150, B9002) provided from March 1, 2020, to May 31, 2020.
You asked the Plan to pay for enteral feeding supplies. You say that these items should be covered because the enrollee's stay was self-paid. The Plan denied your request. The Plan says these items were billed with place of service 31, skilled nursing facility, and are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that enteral feeding supplies was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for enteral feeding supplies (B4035, B4150, B9002) provided from March 1, 2020, to May 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services provided on August 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychiatric services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 psychiatric services provided on August 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on August 6,
2020.

You asked the Plan to pay for the GeneSight Psychotropic testing. 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 payable.

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 GeneSight Psychotropic testing. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has been diagnosed with stage 1 right breast invasive
mammary carcinoma and hepatocellular carcinoma based on biopsy. The documentation does not support that
the enrollee had a diagnosis that meets criteria for the services rendered. The enrollee had not tried other
standard treatments and failed prior to considering testing. Therefore, the enrollee did not meet criteria for the
rendered services.

Review of the file shows that the Plan uses Local Coverage Determination (LCD), L36807 to support their
denial. However, tis LCD is not valid for the correct jurisdiction for the provider's mailing state of Arizona.
Therefore, we cannot use LCD L36807 to substantiate our decision.

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 GeneSight Psychotropic testing have not been met. Therefore, we decided
that the Plan does not have to pay for the GeneSight Psychotropic testing provided on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99223) provided on December 20, 2020.
You asked the Plan to pay for initial hospital care. You say that this should be covered. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also 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 find that CPT code 99223 is not supported in the medical record. Specifically, records were not provided
for the billed date of service. Without this information, the billed code cannot be verified. Based on this
information, we decided that Medicare rules for coverage of initial hospital care have not been met. Therefore,
we decided that the Plan does not have to pay for initial hospital care (99223) provided on December 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve these services. You say that this treatment is considered safe and effective
as supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical
evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says that this service is
considered experimental and investigational.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Current evidence
based medical guideline and peer reviewed literature do not fully support the spinal decompression device
procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peerreviewed
outcome studies to support the use of this device for this enrollee's medical condition. FDA
indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with
moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5.
This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal
stenosis (including the planned level for implantation). FDA contraindications include spinal instability,
scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is
imaging evidence of retrolisthesis with no discussion of spinal instability on flexion/extension films. There is
imaging evidence of dextroconvex curvature of the lumbar spine (with no documentation of the Cobb angle).
There is also no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis
in this patient with documented compression fractures of the lumbar spine. Overall, there is no compelling
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an
exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for
coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Superion interspinous spacer for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided on January 23, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says there were network providers available.
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 lab services (G0483) provided on January 23,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on December 14, 2020.
You asked the Plan to pay for the dental service. You say that this procedure was canceled. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan also says there is no record that you contacted the Plan prior to the date of service to verify benefits or provider eligibility.
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 complete series x-ray (D0210) provided on December 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on May 19, 2020.
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 10, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on May 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for neurobehavioral status examination (96116,
96121) provided December 3, 2020.

You asked the Plan to waive the copayment for neurobehavioral status examination. You say that you paid
your $45 copay so you should not have a balance due on this bill. The Plan denied your request. The Plan says
the claim was processed, and the correct copayment was applied per the Evidence of Coverage.

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 $100
copay for Medicare covered diagnostic procedures and tests.

You have been asked to pay $96.33 for the neurobehavioral status examination. The neurobehavioral status
examination 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 neurobehavioral status examination (96116, 96121)
provided December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 20, 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 27486 and 27335 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 27486 is revision of total knee arthroplasty, with or without allograft; 1 component. The definition of code 27335 is arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area.We find that CPT codes 27486 and 27335 are not supported in the medical record. Specifically, there is no documentation of revision of a total knee arthroplasty with or without allograft for one component to support code 27486. There is no documentation of an arthrotomy of the knee with synovectomy to support code 27335. 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 October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery and an intraocular lens (IOL) provided on
November 24, 2020, by an OON provider.
You asked the Plan to pay for cataract surgery and IOL. You say that you obtained prior authorization for these
services. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this provider is out-of-network with the Plan and authorization was not obtained.
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 cataract surgery and an intraocular lens (IOL)
provided on November 24, 2020, by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing services (T1000) provided on January 23, 2020.

You asked the Plan to pay for nursing services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.

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 T1000 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of nursing services have not been met. Therefore, we decided that the Plan does not have to pay for nursing services (T1000) provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2391), cone beam CT capture and interpretation with limited field of view (D0364), panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and limited oral evaluation - problem focused (D0140) provided December 22, 2020.

You asked the Plan to pay for the dental services. You say that your provider's office called the Plan prior to the services and confirmed that you had not yet reached your dental maximum for 2020. The Plan denied your request. The Plan says the annual limit allowed by your dental plan has already been paid for the year 2020.

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 dental services when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. The Plan provided documentation verifying that your $500 dental allowance was already used to cover services provided June 30, 2020, and July 1, 2020. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2391), cone beam CT capture and interpretation with limited field of view (D0364), panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and limited oral evaluation - problem focused (D0140) provided December 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond April 30, 2021.
You asked the Plan to pre-approve these services. You say that it is not safe for the enrollee to be at home. The Plan denied your request. The Plan says the continued services are not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on April 15, 2021 after hospitalization for altered mental status. The physical therapy note dated April 29, 2021 states she is independent with transfers and walking up to 250 feet. The occupational therapy note states she is independent with bathing, dressing, and toileting. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. 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 continued skilled nursing facility (SNF) services beyond April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on August 12, 2020.
You asked the Plan to pay for the refraction services. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The file shows that you received eye refraction services during a Medicare-covered eye exam. The refraction services are considered routine vision services, and not included as a Medicare-covered benefit. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Unna boot strapping services coded 29580 provided on July 21, 2020.

You asked the Plan to pay for the Unna boot strapping services. 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 payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 29580 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the Unna boot strapping services have not been met. Therefore, we decided that the Plan does not have to pay for the Unna boot strapping services coded 29580 provided on July 21, 2020.