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

We decided that the Plan does not have to pay for the office visit rendered on January 14, 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 claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that Medicare must use the POS codes from the National POS code set for processing its electronically submitted claims.We looked at the file and Medicare rules. The file shows that the office visit was billed with Place of Service (POS) code 12 for the home setting, which is not the appropriate POS code for the services.Therefore, we decided that the Plan does not have to pay for the office visit rendered on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approvea cute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 16, 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 claim was billed incorrectly.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 November 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, 60mg/ml, syringe.

You asked the Plan to pre-approve Prolia. You say that this drug is necessary to prevent future breakage. The Plan denied your request. The Plan says the requested drug is being dispensed by the pharmacy to the enrollee. The Plan also says that this drug is not eligible for coverage under Part B Medicare in this situation.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia, 60mg/ml, syringe.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 2, 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 code G0328 is 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 G0328 is colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous.

We find that CPT code G0328 is not supported in the medical record. Specifically, there is no lab report for the billed test in the submitted documentation. 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 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided by an out-of-network
provider on November 23, 2020.

You asked the Plan to pay for the automatic external defibrillator. The Plan denied your request. The Plan says
this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 automatic external defibrillator provided by an
out-of-network provider on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for palliative treatment of dental pain (D9110) provided on January 13, 2021.

You asked the Plan to pay for the dental care. You say that this service was billed correctly and was not an emergency. You did not know there was a difference between in-network and out-of-network at the time, but you understand now that you would still pay part of the cost and ask that the Plan cover the rest. The Plan denied your request. The Plan says this service is not covered by your dental benefit, regardless of who provides services.

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. We have read your appeal letter and understand that you believe that this service was billed incorrectly, and the claim needs to be corrected. The provider used is not contracted with the Plan, and in order for this claim information to change, the provider in question must submit corrected claim information to the Plan directly for further review.

We cannot act on or process claim corrections; we are only permitted to make a decision based on the claim
information reviewed by the Plan for payment. The service submitted is not covered by the Plan's supplemental
dental benefit. Therefore, we decided that the Plan does not have to pay for palliative treatment of dental pain
(D9110) provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet rich plasma injection provided on November 6, 2020.You asked the Plan to pay forinjection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (0232T). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the clinical value and effectiveness of platelet rich plasma injection for the enrollee's diagnosis has not been demonstrated in the peer-reviewed literature.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 injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (0232T). Our reviewer says that injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not support the medical reasonableness and necessity of the service.  The service is considered experimental and investigational according to the available literature. 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 injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed (0232T) have not been met.Therefore, we decided that the Plan does not have to pay for the platelet rich plasma injection provided on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 12, 2020.You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered.The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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.
In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically,the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met.Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 29, 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 claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that Medicare must use the POS codes from the National POS code set for processing its electronically submitted claims.We looked at the file and Medicare rules. The file shows that the office visit was incorrectly billed with Place of Service (POS) code 12 for a home setting. 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 office visit rendered on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee no longer qualifies for SNF coverage.  The enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.You asked the Plan to pre-approve the monitor. You say that this is medically necessary.The Plan denied your request. The Plan says the criteria for coverage is not met.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 the monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have diabetes and use insulin twice daily. You do not frequently adjust the insulin based upon the testing results. 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 the monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on October 5, 2020.You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). 
Our reviewer says that the ambulance service is not medically reasonable or necessary.Our physician reviewer found that the enrollee is a 74-year-old female who reported nausea and diarrhea as well as severe abdominal pain with constipation. Emergency medical services arrived and found her abdomen non-tender and soft, Glasgow coma scale (GCS) was 15, vitals stable. She was transported via ambulance to the hospital.The presenting symptoms do not meet prudent layperson criteria for emergency care.The documentation does not support that other means of transportation, such as a stretcher van, would be contraindicated for this enrollee. The documentation does not support that the enrollee required expertise or special equipment during transportation. Therefore, the documentation does not support that the ambulance services were medically reasonable or necessary for the enrollee.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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have not been met.Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).You asked the Plan to preapprove the CGM. You say that the CGM should be covered.The Plan denied your request. The Plan says the coverage criteria have not been met in full.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided on November 5, 2020.You asked the Plan to pay for a lumbar-sacral orthosis. You say that the requested item is a medical necessity for the enrollee.The Plan denied your request. The Plan says rules for durable medical equipment have not been met.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces (L1851, L2397) and a back brace (L0648) provided on December 9, 2020.You asked the Plan to pay for knee braces and a back brace. You say that these items should be covered.The Plan denied your request. The Plan says these items were not billed with the most appropriate diagnosis codes.The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. We looked at the file and Medicare rules. The items at issue were billed with both M17.11, unilateral primary osteoarthritis, right knee, and M17.12, unilateral primary osteoarthritis, left knee.There is a more appropriate bilateral diagnosis code that more accurately reports the enrollee's condition.
Based on this information, we decided that Medicare rules for coverage of knee braces and a back brace have not been met.Therefore, we decided that the Plan does not have to pay for knee braces (L1851, L2397) and a back brace (L0648) provided on December 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided by an out-of-network provider on
December 16, 2020.

You asked the Plan to pay for the x-ray. You say that a modifier is allowed to differentiate between the services
provided. You say that medical notes support the medical necessity and should be processed for payment. The
Plan denied your request. The Plan says the services are not authorized because the provider is a non-network
provider with the Plan.

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 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 x-ray provided by an out-of-network provider
on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a specialist visit provided on February 8, 2021.

You asked the Plan to waive the co-payment for a specialist visit. You say that this was a preventative visit and you should not be responsible for 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 say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co-payment for each specialist visit.

The medical records show that you receive diagnostic specialist services on February 8, 2021. Therefore, you are responsible to pay the $45 co-payment.

You have been asked to pay a $45 co-payment 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 co-payment for a specialist visit provided on February 8, 2021.