Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on October 1, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says you have exhausted the allowable benefit for this service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat reason, the Plan's coverage rules apply in this case. We looked at the case fileand the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-ray have not been met.Specifically, the Plan contract states that this service is covered once every five years. This service was previously provided on July 28, 2020,and was subsequently paid for by the Plan. You have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for the specialist office visits provided on August 18,
2020, and August 19, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you had knee surgery
and were only seen at the hospital. You say you never established new patient care with this provider and have
never been to this provider's office. The Plan denied your request. The Plan says that you have been charged
the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not submit medical records to verify you received services from
this provider at her office. The plan has not shown that the copayment amounts you are being asked to pay is
correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayments
for the specialist office visits provided on August 18, 2020, and August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam provided on August 26, 2020. 
 
You asked the Plan to pay for the oral exam. The Plan denied your request. The Plan says you previously 
received a similar exam. 
 
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 file shows that you received a limited oral exam on August 26, 2020. You previously received a limited 
oral exam on August 18, 2020. We looked at the file, and Medicare rules. Your plan only covers 1 limited oral 
exam per plan year. Based on this information, we decided that the Plan's rules for coverage of the oral exam 
have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral exam provided 
on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (64999) provided. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was submitted with an inappropriate CPT code. 
 
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 64999 is Unlisted procedure, nervous system. 
 
We find that CPT code 64999 is not supported in the medical record. Specifically, per National Correct Coding 
Initiative Policy Manual for Medicare Services Chapter II, Section B Standard Anesthesia Coding, an 
anesthesia practitioner may separately report an epidural or peripheral nerve block injection in addition to the 
anesthesia code for certain CPT codes. CPT code 64999 is not one of these codes. Based on this information, 
we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we 
decided that the Plan does not have to pay for anesthesia services (64999) provideD.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Pap Nap.You asked the Plan to pre-approvea Pap Nap. You say that the requested Pap Nap is medically necessary.The Plan denied your request. The Plan says the requested Pap Nap is not medically necessary.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 a Pap Nap. Our reviewer says that the requested Pap Nap is not medically necessary. Our physician reviewer found the requested PAP nap is considered not medically necessary.  This enrollee has moderate obstructive sleep apnea (OSA) and has been prescribed CPAP.  She is having difficulty tolerating the mask interface, despite trying several versions.  However, there are insufficient data to show that PAP nap is effective in improving PAP tolerance, compared with usual measures.  This procedure is not considered standard 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 a Pap Nap have not been met.Therefore, we decided that the Plan does not have to pre-approvea Pap Nap
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy services provided on July 14, 2020.You asked the Plan to pay forphysical therapy services (97110, 97140). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the submitted documentation did not include detailed descriptions of the specific therapeutic exercises performed.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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The CPT Code Manual definition of code  97140 is Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.We find that CPT code 97110 and 97140 arenot supported in the medical record. Specifically, there is no documentation of what exercises were performed or time spent performing the billed services. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay forphysical therapy services provided on July 14, 202
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for trunk repair (13102) provided on August 2, 2019.
You asked the Plan to pay for trunk repair. You say that this should be covered. The Plan denied your request. The Plan says the primary procedure has been denied. Please note that the Plan has indicated they are handing the primary procedure, 13101, is being handled in a separate case.
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 13102 is repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure). We find that CPT code 13102 is not supported in the medical record. Specifically, this is an add on code and the primary procedure has been denied. Based on this information, we decided that Medicare rules for coverage of trunk repair have not been met. Therefore, we decided that the Plan does not have to pay for trunk repair (13102) provided on August 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the selective catheter placement services coded 36215 provided on June 18, 2020.
You asked the Plan to pay for the selective catheter placement 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. In this case, the CPT Code Manual definition of code 36215 is selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. We find that CPT code 36215 is not supported in the medical record. Specifically, the operative report did nit include documentation of a selective catheter placement into the arterial system, for each first order thoracic or brachiocephalic branch, within a vascular family; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the selective catheter placement services have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement services coded 36215 provided on June 18, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transportation provided on February 20, 2020.

You asked the Plan to pay for the ambulance transport. You say that you needed to get to the hospital quickly and had no other option to get there. The Plan denied your request. The Plan says that this was billed as statutorily excluded transportation.

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 transport. Our reviewer says that review of the records shows that the enrollee's condition meets the Medicare definition of an emergency. Our physician reviewer found the enrollee uses a Foley catheter that was not draining and fell out, causing discomfort. He was transported by ambulance to the emergency room. The absence of a necessary Foley catheter could lead to acute renal failure. This situation needed to be rectified immediately to prevent serious jeopardy to the enrollee's health.

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 transport have been met. Therefore, we decided that the Plan has to pay for the ambulance transportation provided on February 20, 2020. 

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) scan capture and interpretation (D0368) provided on September 8, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) scan capture and interpretation (D0368) provided on September 8, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the chest.
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT is medically reasonable and necessary. Our physician reviewer found that there is documentation of a new pulmonary nodule in records. It is medically reasonable and necessary to do the CT scan as requested. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the chest.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of physical therapy.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says imaging studies and an orthopedic evaluation would be more appropriate if there is exacerbation of left knee pain.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for your condition, and the documentation does not indicate that your functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The documentation states you are functioning at the prior level of function, and you are independent in a home exercise program. The requested services are not part of a maintenance program,and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition, or to prevent or slow further deterioration.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of physical therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection testing (87507) provided on July 8, 2020.
You asked the Plan to pay for infectious agent detection testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is only covered for enrollees with immunodeficiency.
The Plan must follow Medicare rules. Medicare rules say that code 87507 is covered in beneficiaries with immunodeficiency. We looked at the file and Medicare rules. The record does not show that the enrollee has immunodeficiency. Based on this information, we decided that Medicare rules for coverage of infectious agent detection testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection testing (87507) provided on July 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 12, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 12, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEntyvio.You asked the Plan to pre-approveEntyvio. You say that the requested Entyvio is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Stelara first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans toimplement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Entyvio. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Crohn's disease, unspecified, without complications. The Plan requires a trial of Stelara first, before they will approve the requested drug. The case file does not contain documentation of trial and failure of Stelara. The documentation does not support that Stelara would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met.Therefore, we decidedthat the Plan does not have to pre-approveEntyvio.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (33361) provided on September 15, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as a clinical trial number was not provided.
The Plan must follow Medicare rules. Medicare rules say that claim lines billed without an 8-digit clinical trials.gov identifier number shall be returned as unprocessable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, a clinical trial number was not provided on the claim form submitted to the Plan. Medicare rules say that claim lines billed without an 8-digit clinical trials.gov identifier number shall be returned as unprocessable. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement (33361) provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe RT300 FES Cycle Ergometer (External Functional Neuromuscular stimulator, E1399).You asked the Plan to pre-approvethe FES cycle. You say that this is the only device that will aid in your recovery.The Plan denied your request. The Plan says you do not meet coverage criteria for an FES/NMES device.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our 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 FES cycle. Our reviewer says that the requested items/services are not considered to meet Medicare criteria laid out in the NCD. Our reviewerfound there's no documentation that the enrollee can demonstrate balance and control to maintain upright support posture independently; or that the enrollee can transfer independently, or demonstrate independent standing tolerance for at least 3 minutes.We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the FES cycle have not been met.Therefore, we decided that the Plan does not have to pre-approvethe RT300 FES Cycle Ergometer (External Functional Neuromuscular stimulator, E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora targeted genomic sequence analysis panel (81445) provided on September 17, 2020.You asked the Plan to pay forthe targeted genomic sequence analysis panel. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says these services were not medically necessary.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 targeted genomic sequence analysis panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition.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 targeted genomic sequence analysis panel have not been met.Therefore, we decided that the Plan does not have to pay fora targeted genomic sequence analysis panel (81445) provided on September 17, 2020