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

We decided that the Plan does not have to pay for 20 units of CPT code J3490 provided on November 13,
2019.
You asked the Plan to pay for 20 units of CPT code J3490. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the services are not supported as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 20 units of CPT code J3490 are not supported in the medical record. The medical record only
supports 1 unit of CPT code J3490. Based on this information, we decided that Medicare rules for coverage of
20 units of CPT code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for 20
units of CPT code J3490 provided on November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services You asked the Plan to pre-approve the continuation of SNF care. You say that the records provided support the need for a continuation of SNF care.The Plan denied your request. The Plan says the enrollee is medically stable. The Plan says that the enrollee's needs can be safely and better managed in a less restrictive setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy, speech therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a maximal assist to dependent for care and functional mobility. The enrollee tolerated a mechanical soft diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (11719 and 11720) provided on December 18, 2019.
You asked the Plan to pay for the podiatry services. You say that you would like reconsideration because the member was seen on this date of service in the nursing facility. The Plan denied your request. The Plan says the place of service is inconsistent with the patient being in a registered inpatient status.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We find that CPT code 11719 and 11720 is not supported in the record. Specifically, the record indicates that the member was registered inpatient on this date of service. The place of service billed on this claim is inconsistent with their being registered inpatient. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services (11719 and 11720) provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 13, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. 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 has network providers available who can provide 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 physician services provided on June 13, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services.. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the requested services are for the treatment of knee pain. The requested service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve chiropractic services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 30 and 31, and core build up (D2950) for tooth # 30.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says porcelain crowns and core build up are not listed as covered 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 30 and 31, and core build up (D2950) for tooth # 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for PET imaging (78812) and CT imaging (74176) provided on November 25, 2019. You asked the Plan to pay for the imaging. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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 CPT Code Manual definition of code 78812 is Positron emission tomography (PET) imaging; skull base to mid-thigh. The CPT Code Manual definition of code 74176 is Computed tomography, abdomen and pelvis; without contrast material. 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 imaging. Our reviewer says that CPT code 78812 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include a radiology report to corroborate a Positron emission tomography (PER) imaging; skull base to min-thigh being performed on November 25, 2019, therefore this service cannot be verified. Our reviewer found CPT code 74176 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include a radiology report to corroborate that a Computed tomography, abdomen and pelvis; without contrast material was performed on November 25, 2019, therefore this service 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 imaging have not been met. Therefore, we decided that the Plan does not have to pay for PET imaging (78812) and CT imaging (74176) provided on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient surgical procedure provided on December 3, 2019.You asked the Plan to waive the coinsurance for an inpatient surgical procedure. You say that you were never told that you were receiving inpatient services and thought that the procedure was considered outpatient.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for inpatient hospital care. The medical records show that you received an inpatient surgical procedure on December 3, 2019. The allowed mount is $1,397.28 and 20% of that is $279.46. You have been asked to pay the total coinsurance amount of $279.46 for an inpatient surgical procedure. An inpatient surgical procedure falls within the inpatient hospital 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 coinsurance for an inpatient surgical procedure provided on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram report (93010) provided December 18, 2019. You asked the Plan to pay for the electrocardiogram report. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says the records do not support the billed services. 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 93010 is not supported in the medical record. Specifically, no electrocardiogram interpretation report was included. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram report have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram report (93010) provided December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet light therapy system.
You asked the Plan to pre-approve an ultraviolet light therapy system. You say that you need ultraviolet light therapy for your skin condition. The Plan denied your request. The Plan says your skin condition is not a covered diagnosis for ultraviolet light therapy.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The record does not show you have psoriasis. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light therapy system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the recliner chair (E1031).
You asked the Plan to pre-approve the recliner chair. You say that you are unable to lie flat in a bed and prefers to sleep in a recliner that is currently borrowed for comfort and you would like your own recliner. The Plan denied your request. The Plan says this item is a convenience and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the recliner chair (E1031).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomographic angiography (CTA) provided on
November 7, 2019.
You asked the Plan to pay for the CTA. You say that the tests were ordered and approved by your primary care
physician. The Plan denied your request. The Plan says the service has been previously processed under a
different claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim are denied.
In this case, the CPT Code Manual definition of code 72191 is Computed tomographic angiography, pelvis,
with contrast material(s), including non-contrast images, if performed, and image post-processing. We find that
CPT code 72191 has been processed on a previous claim billed to the plan. Duplicate claims or claim lines are
not payable. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pay for the computed tomographic angiography (CTA)
provided on November 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic imaging services to be provided by an out of area provider.
You asked the Plan to pre-approve the requested services. You say that you have not been able to travel back home. The Plan denied your request. The Plan says in-network, contracted provider are readily available.
Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
The requested services are not considered unforeseen, as they were ordered prior to leaving the service area. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve diagnostic imaging services to be provided by an out of area provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on November 5, 2019.You asked the Plan to pay for the drug 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 supported by the documentation.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 80307 and G0480 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID-19. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the acupuncture services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are in-network acupuncturist's available to you that can provide the services you are requesting. The Plan responded to our request for information and says they will approve the requested services as long as they are provided by an in-network provider. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0365), two sinus augmentations with bone or bone substitutes (D7951 x2), and repair of maxillofacial soft and/or hard tissue defect (D7955).
You asked the Plan to pre-approve the cone beam CT capture and interpretation, sinus augmentations, and repair of maxillofacial soft and/or hard tissue defect. You say that you are on a fixed income. You also say that you have a broken molar that is piercing your sinus cavity, which is causing you pain. The Plan denied your request. The Plan says these services are not covered benefits. 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 pre-approve a cone beam CT capture and interpretation (D0365), two sinus augmentations with bone or bone substitutes (D7951 x2), and repair of maxillofacial soft and/or hard tissue defect (D7955).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a car transfer lift for the enrollee.
You asked the Plan to pre-approve a car transfer lift. The Plan denied your request. The Plan says that your request is not medically necessary because the item is useful in the absence of disease, it would be used outside of the home and it is not primarily medical in nature.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a car transfer lift for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee. You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says that there was no clinical information provided indicating that the member meets criteria. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2020.
You asked the Plan to pay for the laboratory 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 supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, the documentation
submitted did not include a physician/lab requisition form or medical records stating exactly what tests were to
be performed. Based on this information, we decided that Medicare rules for coverage of the laboratory
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on January 13, 2020.