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

We decided that the Plan does not have to pay for the closed treatment of vertebral body fractures (22310) provided on July 9, 2019.You asked the Plan to pay for the closed treatment of vertebral body fractures. You say that this should be covered.The Plan denied your request. The Plan says this code is note 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 22310 is closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing.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 closed treatment of vertebral body fractures.Our reviewer says that CPT code 22310 is not supported by the medical records. Our physician reviewer found the documentation does not mention closed treatment of a vertebral fracture without manipulation. The record mentions a planned surgical procedure to treat the fractured vertebra.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 closed treatment of vertebral body fractures have not been met.Therefore,we decided that the Plan does not have to pay for the closed treatment of vertebral body fractures (22310) provided on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis provided by "the provider" on March 15, 2019.You asked the Plan to pay forthe wrist hand orthosis (L3916). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, wedecided that the Plan does not have to pay forthe wrist hand orthosis provided by "the provider" on March 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Premarin.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by the plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Premarin.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthosis provided to the enrollee on January 30, 2019.You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary.The Plan denied your request. The Plan says that the billed services were not supported.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe ankle/foot orthosis provided to the enrollee on January 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to "the beneficiary" by "the provider" on July 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more classes.We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered to "the beneficiary" by "the provider" on July 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 23, 2019 through July 30, 2019.You asked the Plan to pay for the home infusion therapy. You say that S9328 is valid per CMS. The Plan denied your request. The Plan says S9328 has a status code of I which is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status indicator of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 23, 2019 through July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the arthrocentesis or the Part B drug injections provided on July 18, 2019.You asked the Plan to waive the cost share for the arthrocentesis and the Part B drug injections. You say that you were told this service was covered. You say you cannot afford to pay this amount as it would be a hardship.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $40 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office and 20% coinsurance for each in-network Medicare-covered Part B drug.
You have been asked to pay a total cost share amount of $339.63 for the arthrocentesis and the Part B drug injections. The arthrocentesis falls within the "Physician/Practitioner Services, Including Doctor's OfficeVisits" benefit category. The Part B drug injections fall within the services "Medicare Part B Prescription Drugs" 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 cost share for the arthrocentesis or the Part B drug injections provided on July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 21, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 63048 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 63048 is partial removal of spine bone with release of spinal cord and/or nerves, add-on (List separately in addition to code for primary procedure).We find that CPT code 63048 is not supported in the medical record. Specifically, this code is an add-on code and it was not billed with the required primary procedure code. 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 August 21, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on July 5, 2019.You asked the Plan to pay for the surgical services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 surgical services provided on July 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha. The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 22, 2019.You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 and the referring provider are not network providers with the Plan. 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 laboratory testing provided on July 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on July 21, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 23650 and 99152 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 23650 is closed treatment of shoulder dislocation, with manipulation; without anesthesia. The definition of code 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT codes 23650 and 99152 are not supported in the medical record. Specifically, the documentation does not contain a detailed procedure report to support that closed treatment of a shoulder dislocation was performed to support 23650. The documentation does not contain documentation of an independent trained observer to assist with monitoring to support code 99152. 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 services rendered July 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy (HIT) services provided from August 13, 2019 to August 20, 2019.You asked the Planto pay forthe HIT services. You say that this is a valid code according to the CMS website and no alternative code has been provided to allow for payment of these services.The Plandenied your request. The Plansaysthis code is not valid for Medicarebilling.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.CPT code S9328 has a status indicator of "I" meaning that it is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe home infusion therapy (HIT) services provided from August 13, 2019 to August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve two quadrants for periodontal scaling and root planing.We decided that the Plan does nothave to pre-approve the remaining two quadrants.You asked the Plan to pre-approve the periodontal scaling and root planing. You say that you suffer from bleeding gums and pain when you eat.The Plan denied your request. The Plan says that this serviceis only allowed one time in twenty-four months.We decided that the Planhas to pre-approve two quadrants for periodontal scaling and root planing.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. There were no records submitted to support that the Plan has paid for periodontal scaling and root planing to exhaust thebenefit.Therefore, we decided that the Plan has to pre-approve two quadrants for periodontal scaling and root planing.We also decided that the Plandoes not haveto pre-approve the remaining two quadrantsYour contract with the Plan clearly says thatonly two quadrants will be reimbursed on the same date of service. Therefore, we decided the plan does not have to pre-approve the remaining two quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) provided on July 23, 2019.
You asked the Plan to pay for needle electromyography. You say that these services were billed correctly and
should be paid. The Plan denied your request. The Plan says 95999 would be a more appropriate code for the
services rendered.
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 95861 is needle electromyography; 2 extremities with or
without related paraspinal areas.
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 needle electromyography. Our reviewer says
that CPT code 95861 is not supported by the medical record. Our physician reviewer found the documentation
does not contain evidence that needles were placed to measure electrical activity. It cannot be verified that the
services described by CPT code 95861 were performed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the
Plan does not have to pay for needle electromyography (95861) provided on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain or ceramic crowns on tooth #'s 9, 10, and 12,
and core buildups, including any pins when required on tooth #'s 9, 10, and 12.
You asked the Plan to pre-approve the porcelain or ceramic crowns and core buildups. You say that you
constantly have pain in your mouth from dentures you have had for more than 25 years. The Plan denied your
request. The Plan says these services are not medically necessary.
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 porcelain
or ceramic crowns and core buildups when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the porcelain or ceramic crowns and
core buildups. Our reviewer says that the service is not medically necessary. Our physician reviewer found the
documentation did not state the reason for the replacement of the crowns on tooth #'s 9, 10, and 12. Our
reviewer found that the radiographs did not reveal any recurrent caries or marginal defects. Our physician
reviewer also found that the documentation does not support that the porcelain or ceramic crowns on tooth #'s
9, 10, and 12, and core buildups, including any pins when required on tooth #'s 9, 10, and 12 are medically
reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the porcelain or ceramic crowns and core buildups have not been met.
Therefore, we decided that the Plan does not have to pre-approve porcelain or ceramic crowns on tooth #'s 9, 10, and 12, and core buildups, including any pins when required on tooth #'s 9, 10, and 12.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forneedle electromyography (95885), nerve conduction studies (95909), and an electroencephalogram (95955) provided on July 18, 2019.You asked the Plan to pay forneedle electromyography, nerve conduction studies, and an electroencephalogram. You say that these codes should be paid.The Plan denied your request. The Plan says these codes are not supported by the records.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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of 95909 is nerve conduction studies; 5-6 studies, and 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).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 needle electromyography, nerve conduction studies, and an electroencephalogram. Our reviewer says that CPT codes 95885 and 95909 are not supported by the medical record. The record states that pedicle screw stimulation and triggered EMG was performed. According to coding rules, there is a more specific code for this procedure. CPT code 95955 is not supported. The record does not contain evidence that a diagnostic EEG was performed during this episode of care. The record states that continuous intraoperative monitoring was performed. According to CPT rules, there is a more specific code for this procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography, nerve conduction studies, and an electroencephalogram have not been met.Therefore, we decided that the Plan does not have to pay forneedle electromyography (95885), nerve conduction studies (95909), and an electroencephalogram (95955) provided on July 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional behavioral psych testing for the enrollee.
You asked the Plan to pre-approve the additional testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical necessity for the amount of care requested.
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 additional testing. Our reviewer says that the requested additional testing are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee regularly uses cannabis, which would affect the results of the testing, making the testing not medically necessary. The enrollee does not meet the criteria for neuropsychological testing therefore it is not medically necessary or reasonable to have neuropsychological testing as outlined as this enrollee does not suffer from a neurologic condition based on the workup obtained. 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 additional testing have not been met. Therefore, we decided that the Plan does not have to pre-approve additional behavioral psych testing for the enrollee.