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

We decided that the Plan does not have to pay for the neuroplasty(64718) and endoscopy (29848) provided.

You asked the Plan to pay for the neuroplasty and endoscopy. You say that you would like reconsideration because the Plan was not prejudiced in late filing.The Plan denied your request. The Plan says this claim was not filed within the 12 month allowable timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the neuroplasty and endoscopy was not filed. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the neuroplasty (64718) and endoscopy (29848) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered.

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 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services (A0429-QL) provided on April 3, 2020.You asked the Plan to pay forambulance services. You say that this was billed correctly.The Plan denied your request. The Plan says this was billed withan incorrect code and modifier combination.The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers reportthe A0428 HCPCS codeandmodifier QL.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances.Therefore, we decided that the Plan does not have to pay forambulance services (A0429-QL) provided on April 3, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by Phoenix Paramedic Solutions on August 12, 2020.You asked the Plan to pay forthe 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 August 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 forthe ambulance services provided by Phoenix Paramedic Solutions on August 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 23, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 the medical services provided on September 23,
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-raywith dental code D0330 provided on September 1, 2020.You asked the Plan to pay forthe panoramic x-ray with dental code D0330. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says a panoramic x-ray is not a covered dental service under the supplemental dental benefit. The Plan has authorized payment for the rest of the dental services you received on the date of service at issue in this appeal (D1110, D0272, and D0150).Medicare generallydoes 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 panoramicx-ray (D0330) is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray with dental code D0330 provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and abutment
supported crowns (D6057) for teeth # 21 and 29.
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan
denied your request. The Plan says prefabricated abutments are not listed as covered services. The Plan also
says that abutment supported crowns are not listed as covered services either.
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
prefabricated abutments (D6056) and abutment supported crowns (D6057) for teeth # 21 and 29.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services (A0429) provided April 8, 2020.You asked the Plan to pay forthe ambulance services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not reported using the proper coding.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 A0429 is not supported in the medical record. Specifically, the record shows the patient was deceased prior to ambulance arrival. In this case, providers must report the A0428 (BLS) HCPCS code. Providers must report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services (A0429) provided April 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2330) provided on August 10, 2020.
You asked the Plan to pay for the dental service. You say that you received 2 bills for fillings. You say that you
were not told only 2 fillings were covered at your appointment. You also say that this bill is a financial
hardship for you as you are on a fixed income. The Plan denied your request. The Plan says 2 fillings per
calendar year are covered. The Plan also says that the frequency limit for this service has been exceeded.
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 frequency limit of 2 fillings per
calendar year has been exceeded. The record shows that the Plan paid for 2 fillings that you received on May
15, 2020. Therefore, we decided that the Plan does not have to pay for the filling (D2330) provided on August
10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429-QL) provided.

You asked the Plan to pay for ambulance services. You say that this was billed correctly.The Plan denied your request. The Plan says this was billed with an incorrect code and modifier combination.

The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 HCPCS code and modifier QL.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances.Therefore, we decided that the Plan does not have to pay for ambulance services (A0429-QL) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forambulance services (HCPCS A0429-QL) provided to the enrollee on August 30, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim was not billed according to CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called.Medicare requires the reporting of A0428 for services provided under these circumstances.  Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forambulance services (HCPCS A0429-QL) provided to the enrollee on August 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent 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 physician's services. 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 physician's services that you provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on July 12, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year afterthe date of service.The record shows that a claim for the services was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided on July 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fordebridement (11044) and the application of a skin substitute (15275) provided on July 6, 2020.You asked the Plan to pay forthe debridement and application of a skin substitute. 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.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 debridement and application of a skin substitute. Our reviewer says that CPT code 11044 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient procedural documentation to validate that a Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less was performed on July 6, 2020. Our reviewerfound CPT code 15725 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation for validate that an Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area was performed on July 6, 2020.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 debridement and application of a skin substitute have not been met.Therefore, we decided that the Plan does not have to pay fordebridement (11044) and the application of a skin substitute (15275) provided on July 6, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that your physician advised compression stockings to avoid blistering and open wounds.The Plan denied your request. The Plan says compression stockings are non-covered because they do not meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the Prolia is
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy
exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement 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 Prolia. Our reviewer says that the
documentation does not show that the member has tried and failed an oral bisphosphonate drug and zoledronic
acid, as required by the Plan Our physician reviewer found the documentation does not show that the required
drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forneedle electromyography (95885), nerve conduction studies (95908) and the EEG (95955) provided on July 13, 2020.You asked the Plan to pay forthe needle electromyography, nerve conduction studies and EEG. 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.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 needle electromyography, nerve conduction studies and EEG. Our reviewer says that CPT code 95885 does not meet criteria for billing or reimbursement consideration. The medical records provided do not document that a limited needle electromyography with nerve conduction was performed.  The medical records document that pedicle screw stimulations were performed and are not baseline nerve conduction studies, therefore this service cannot be verified. Our reviewer found CPT code 95908 does not meet criteria for billing or reimbursement consideration.  The medical records provided do not document that a nerve conduction study of 3-4 studies was performed.  The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95908. Additionally, CPT code 95995 does not meet criteria for billing or reimbursement consideration. The medical records provided indicate that real timeEEG monitoring was performed.  This service does not meet definition requirements of CPT 95955, 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 needle electromyography, nerve conduction studies and EEG have not been met.Therefore, we decided that the Plan does not have to pay forneedle electromyography (95885), nerve conduction studies (95908) and the EEG (95955) provided on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you do not need a multidisciplinary team or visits from a physician to monitor him three times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID infection and have been discharged home where home health services are being provided. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission andservices.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex device.You asked the Plan to pre-approvea Vertiflex device. You say that the requested Vertiflex device is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex device 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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is diagnosed with spinal stenosis. The requested Vertiflex device is experimental. More research is needed to show safety and efficacy. There is no spinal instability documented in this case. The requested Vertiflex device is not medically necessary.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex device.