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

We decided that the Plan does not have to pay for the excision services coded 11603 and 11602 and the repair
services coded 12034 provided on October 1, 2020.
You asked the Plan to pay for the excision services and the repair 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 CPT codes 11603, 11602 and 12034 are not supported in the medical record. Specifically, the
documentation submitted did not include size documentation of excision, malignant lesion including margins,
trunk, arms, or legs; excised diameter 2.1 to 3.0 cm; therefore, code 11603 cannot be verified. The
documentation submitted did not include size documentation of excision, malignant lesion including margins,
trunk, arms, or legs; excised diameter 1.1 to 2.0 cm; therefore, code 11602 cannot be verified. The
documentation submitted did not include size documentation of Repair, intermediate, wounds of scalp, axillae,
trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm; therefore, code 12034 cannot be
verified. Based on this information, we decided that Medicare rules for coverage of the excision services and
the repair services have not been met. Therefore, we decided that the Plan does not have to pay for the excision
services coded 11603 and 11602 and the repair services coded 12034 provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the maxillary partial denture (D5225) and mandibular partial denture (D5226).
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that you would like these services to be covered. The Plan denied your request. The Plan says that you do not meet the coverage criteria due to the condition of your remaining teeth.
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 maxillary partial denture and mandibular partial denture 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 maxillary partial denture and mandibular partial denture. Our reviewer says that the criteria for coverage for a maxillary partial denture (D5225) and a mandibular partial denture (D5226) have been met. Our physician reviewer found the review of your dental record and radiographs indicates that crowns have been approved for teeth #'s 18 and 32. Some of the remaining maxillary teeth appear to have a poor prognosis for retention. Our reviewer found that the remaining mandibular teeth appear to have adequate bone support to support a partial denture. Also, there appears to be a number of maxillary teeth that have adequate bone support to support a partial denture. Our physician reviewer also found that maxillary and mandibular partial dentures are medically reasonable and necessary to provide you with adequate masticatory function. 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 maxillary partial denture and mandibular partial denture have been met. Therefore, we decided that the Plan has to pre-approve the maxillary partial denture (D5225) and mandibular partial denture (D5226).
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 pre-approve the removal of torus mandibularis (D7473).
You asked the Plan to pre-approve removal of torus mandibularis. You say that the requested service should be covered. The Plan denied your request. The Plan says this benefit is covered for a maximum of twice per lifetime.
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 exceeds those covered under this benefit. The Plan has provided evidence that you reached the lifetime limit for this service. Therefore, we decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 88381 and G0452 provided on September 2, 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 CPT codes 88381 and G0452 are not supported in the medical record. Specifically, there is a more appropriate code to report the service provided; therefore, code 88381 cannot be verified. The documentation submitted does not support the coding criteria for code billed on date of service. Lab results submitted do not include separate physician interpretation; therefore, code G0452 cannot be verified. 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 coded 88381 and G0452 provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6750 x2), core buildups (D2950 x2), and
pontic (D6240) provided on November 12, 2020.
You asked the Plan to pay for retainer crowns, core buildups, and pontic. You say that these services were
medically necessary and should be covered. The Plan denied your request. The Plan says these services are not
a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for retainer
crowns (D6750 x2), core buildups (D2950 x2), and pontic (D6240) provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology services provided on July 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for oncology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for oncology services provided on July 16, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is considered safe and effective. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested service is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental/investigational procedure because of the re-operation rate and lack of clinical practice guidelines from learned societies. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide a positron emission tomography (PET) scan.
You asked the Plan to provide a PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). You say that you need a PET scan. The Plan denied your request. The Plan says criteria is not met for a PET CT initial staging of prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that PET 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 provide a PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). Our reviewer says that the service is not reasonable and medically necessary. Our physician reviewer found clinical studies suggest that PET imaging for initial staging of prostate cancer may be helpful in patients with high-risk disease. The medical records provided do not indicate evidence of high-risk disease and the request is not indicated at this time. 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 PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) have not been met. Therefore, we decided that the Plan does not have to provide a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a quantitative calcium scoring procedure (75571).
You asked the Plan to pre-approve quantitative calcium scoring. You say that the requested service is medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service. We looked at the file and Medicare rules. The request is for a service not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve a quantitative calcium scoring procedure (75571).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 25, 2020 and billed under code 71045.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says this claim denied because code 71045 is a column II procedure to the column I procedure 77001 and 36558 which was processed and paid on a previous claim. Medicare billing guidelines have identified column I procedure codes and their associated column II procedure codes based on the principles of correct coding. Services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code. Per the CMS NCCI Policy Manual, Chapter 1, "Occasionally, a provider may perform two procedures that should not be reported together based on an NCCI PTP edit. If the edit allows use of NCCI PTP-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI PTP associated modifier." Since an applicable modifier to bypass the PTP edit was not billed on the claim to represent the services as separate/distinct, the claim is being upheld.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary use the appropriate modifiers. In this case, the claim submitted cannot be paid as billed due to the omission of a required modifier. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 25, 2020 and billed under code 71045.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve ultrasonic guidance for a pain pump refill (76942).
You asked the Plan to pre-approve ultrasonic guidance. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says that says the request for ultrasound guidance is not medically necessary however, the refilling of the enrollee's pain pump has been approved
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 ultrasonic guidance. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found medical records are provided that indicate the ultrasound is used to verify port location and ensure the absence of fluid collection prior to fill. The pump is being filled with an opioid. The ultrasound is also used to confirm the absence of extravasation, or pocket fill, following the fill. The use of ultrasound is medically reasonable and necessary according to the documentation provided. The requested service is recommended We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasonic guidance have been met. Therefore, we decided that the Plan has to pre-approve ultrasonic guidance for a pain pump refill (76942).
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 8 additional physical therapy visits.
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that the requested 8 additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the requested 8 additional physical therapy visits are not medically necessary.
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 8 additional physical therapy visits. 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had extensive therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee should be competent in a home exercise program. Furthermore, the enrollee's diagnosis is unclear, and the neurology consult may provide further clarification on the best treatment option for this enrollee's condition. The requested services are not part of a maintenance program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on September 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid even though the patient was self-referred. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that these services can be 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialist services provided on September 18, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional physical therapy (PT) sessions.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these 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 enrollee has received 25 PT sessions and for poor balance and difficulty walking with his walker. The records do not support that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Further therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Five additional therapy sessions to transition to the home exercise program appears appropriate at this point. The unique skills of a professional therapist are not required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The services are not part of a maintenance program and further therapy would not likely achieve any significant improvement in the enrollee's symptoms or functional status.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional physical therapy (PT) sessions.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that you found that paramedic intercept services are covered by Medicare provided at the paramedic intercept service is billed in conjunction with the ambulance service. 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 pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that this provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an angioplasty to be provided by an OON provider.
You asked the Plan to pre-approve an angioplasty. You say that you would like to see this doctor because he
performed your surgery three years ago. The Plan denied your request. The Plan says there are in-network
providers available for these services.
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
an angioplasty to be provided by an OON provider.