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

We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services represented by code 99213 provided on January 20, 2021.
You asked the Plan to pay for code 99213. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says providers should use the diagnosis code for billing that describes the patient's diagnosis, symptom, complaint, condition or problem to the highest level of specificity. In this case, the records do not support the billing of diagnosis codes H35.3211 and H35.3221. There is a more appropriate bilateral diagnosis code for the services provided. Therefore, we decided that the Plan does not have to pay for the office visit services represented by code 99213 provided on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACHs
do not provide clinical advantage over non-LTACH hospitals.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that the enrollee presented to the hospital breathing inadequately. He was intubated and
evaluated and treated with fluids and pressors. The enrollee is receiving appropriate care at the present acute
care hospital. He does not require services at the LTACH that are not available at the acute care hospital where
he is currently receiving care. There are no services available at the LTACH that he requires that are not
available at the health care setting being offered by the health plan. Therefore, the requested LTACH services
are 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral evaluation (D0120), prophylaxis (D1110),
the bitewing x-ray (D0274), the crown (D2750), and the amalgam (D2150) provided from January 21, 2021, to
February 10, 2021.
You asked the Plan to reimburse you for the dental services. You say that you have been seeing this dentist for
years. You also say that you have previously been reimbursed for preventive dental care with this provider. The
Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says
that payment cannot be made for dental services performed by a provider who has opted out of Medicare.
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 and the services are listed as covered,
dental services performed by a provider who has opted out of Medicare are not eligible for payment. Therefore,
we decided that the Plan does not have to reimburse you for the oral evaluation (D0120), prophylaxis (D1110),
the bitewing x-ray (D0274), the crown (D2750), and the amalgam (D2150) provided from January 21, 2021, to
February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 17, 2021.
You asked the Plan to pay for the chiropractor office visit. You say that your doctor suggested chiropractic services for the numbness in your legs. The Plan denied your request. The Plan says chiropractic office visits are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from January 1, 2020 to January 11, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that SNFs billing on Type of Bill (TOB) 21X must be billed with a Patient Driven Payment Model (PDPM) revenue code. We looked at the file and Medicare rules. The file shows that the claims were not billed with a PDPM revenue 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 skilled nursing facility (SNF) services rendered from January 1, 2020 to January 11, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a monitoring feature on a CPAP device (A9279) provided January 20, 2021 to February 20, 2021.
You asked the Plan to pay for the monitoring feature. You say that this feature is part of your CPAP device and it is medically necessary. The Plan denied your request. The Plan says that the feature was billed with a CPT code that is invalid for Medicare purposes and therefore cannot be covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the monitoring feature by a contract provider. The file does not show that the Plan provided notice that the monitoring feature would not be covered. The Evidence of Coverage does not state that this item would be non-covered. A contract provider must ensure that items are coded properly following Medicare rules. Therefore, we decided that the Plan has to pay for a monitoring feature on a CPAP device (A9279) provided January 20, 2021 to February 20, 2021.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 12, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. 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 payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Colorado. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on June 12, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that you never received a bill from this service in the past. The Plan denied your request. The Plan says this item is not a covered benefit.
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 in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided October 30, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment testing / panels, except the basic lipid panel.
We looked at the file and Medicare rules. The service at issue was a cardiovascular risk assessment panel. This
service is not covered under Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab
services (81479) provided October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 18, 2021 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 physician services provided on February 18, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurological monitoring services and supplies provided on August 17, 2020, billed with codes 95861, 95868, 95927, 95938, 95939, and A4215.
You asked the Plan to pay for the neurological monitoring services. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says two of the billed codes have been approved for payment. The remaining codes cannot be paid as the POS code reported is not correct.
The Plan must follow Medicare rules. Medicare rules say that for services rendered to inpatients must be reported with the inpatient POS code. In this case, the services were reported with POS code 15. Since the enrollee was a registered inpatient, this POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for the neurological monitoring services and supplies provided on August 17, 2020, billed with codes 95861, 95868, 95927, 95938, 95939, and A4215.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS)
unit.
You asked the Plan to pre-approve a TENS unit. You say that this request is medically necessary. The Plan
denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that an enrollee must be enrolled in a clinical study
for coverage of the TENS unit.
We looked at the file and Medicare rules. In this case, there is no evidence the enrollee is enrolled in an
approved clinical study. Based on this information, we decided that Medicare rules for coverage of a TENS
unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous
electrical nerve stimulation (TENS) unit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular risk testing provided on January 22, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular risk testing provided on January 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the family psychotherapy services rendered on March 11, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate primary diagnosis 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 family psychotherapy services rendered on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network (OON) provider on January 26, 2021.
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 was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network (OON) provider on January 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiofrequency ablation (RFA) of the cervical and thoracic spine.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met.
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
the services are medically necessary. Our physician reviewer found the enrollee has chronic neck pain and
headaches. He had right RFA of the medial branches of the C2 to C4 levels in November of 2019 and on July
21, 2020. The progress note states he had resolution of pain after these procedures, until recently. Pain relief
from RFA typically lasts six months or more. The enrollee received pain relief for almost a year and a half
from the prior procedures. Repeat RFA is reasonable or 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 these services have been met. Therefore, we decided that the Plan has to preapprove
radiofrequency ablation (RFA) of the cervical and thoracic spine.
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 pay for the physical therapy services rendered on October 8, 2020.
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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an oral surgeon (99203).
You asked the Plan to pre-approve an oral surgery consultation. You say that you need to see an oral surgeon who can finish the work that you feel has been left unfinished by other providers you have seen. You say you need the extracted teeth replaced, and you have dental insurance, but this does not cover surgeries or major dental work. You are requesting that these services be covered by the Plan and Medicare. The Plan denied your request. The Plan says the records show that your previous tooth extractions were provided for dental reasons and this provider states that you require no further surgery. You are looking for a consultation with another provider because you feel the work was unfinished. There is no indication that these services are requested in relation to a tumor or preparing the jaw for chemotherapy.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a consultation with an oral surgeon (99203).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), the unspecified preventative procedure, by report (D1999) provided April 6, 2021.
You asked the Plan to pay for the periodic oral exam, dental cleaning, and unspecified preventative procedure. You say that you were unaware you needed to go to a dentist who is credentialed with Medicare. The Plan
denied your request. The Plan says the services were provided by a provider who has opted out of Medicare and therefore the services are not covered.
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 periodic oral exam, dental cleaning and unspecified preventative procedure when you use a licensed dental provider who has not opted out of Medicare. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning and unspecified preventative procedure have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), the unspecified preventative procedure, by report (D1999) provided April 6, 2021.