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

We decided that the Plan does not have to pay for ophthalmology services (CPT 66984) provided to the
enrollee on November 14, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 66984-55-79-LT (1 Unit) remains 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 66984 is "Extracapsular cataract removal with insertion
of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration
or phacoemulsification); without endoscopic cyclophotocoagulation."
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
enrollee underwent cataract extraction and lens implantation with laser on 11/7/19. CPT code 66984-55-79-LT
(1 Unit) was billed. Modifier 55 indicates post-operative management. The units are used to indicate the exact
number of post-operative days the provider cares for the patient. On 11/14/19, the enrollee underwent cataract
surgery on the left eye. The enrollee was seen in follow-up on 11/15/19. The documentation does not support
the billing of CPT code 66984-55-79-LT (1 Unit). The cataract procedure has a 90-day postoperative period
included in the global package; postoperative management by the same physician is not payable as a separate
service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for ophthalmology services (CPT 66984) provided to the enrollee on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because the provider rendered medically necessary services in good faith. The Plan denied your request. The Plan says utilization of network providers is required 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 has network providers available who can provide 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 January 22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #6.
You asked the Plan to pre-approve the crown for tooth #6. You say that tooth #'s 3 & 6 are overerupted with the subsequent enlargement of the clinical crown, and a decrease of the intermaxillary space. You also say that these teeth have previous large restorations. The Plan denied your request. The Plan says the documentation shows no evidence of pathologic destruction to the tooth involving four or more surfaces and at least 50% of the incisal edge.
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 crown for tooth #6 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 crown for tooth #6. Our reviewer says that the service is not medically necessary. Our physician reviewer found the criteria for coverage for a crown (D2750) for tooth #6 have not been met since it does not meet the criteria for coverage of a significant (<50%) portion of the coronal aspect of the tooth broken down by caries or fracture. 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 crown for tooth #6 have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #6.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient mental health care stay provided from January 15, 2020 to January 28, 2020.You asked the Plan to pay for inpatient mental health care stay. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this inpatient stay is correct, because inpatient level of care was not medically necessary and the appropriate level of care would have been outpatient services.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pay for inpatient mental health care stay. Our reviewer says that this inpatient stay does not meet the Medicare criteria for coverage. Our physician reviewer found based upon review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions, and was not showing any behavioral issues or withdrawal symptoms. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purposes of diagnosis. The enrollee was treated under an individualized treatment plan. The records for this stay were supervised and evaluated by physician.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care stay have not been met.Therefore, we decided that the Plan does not have to pay for an inpatient mental health care stay provided from January 15, 2020 to January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride -excluding varnish and oral hygiene instructions provided on February 26, 2020.You asked the Plan to pay forthe topical application of fluoride and oral hygiene instructions. You say that you were not informed that the topical application of fluoride (D1208) would be an additional cost. You also say that you do not know why they charged you for the oral hygiene instructions (D1330).The Plan denied your request. The Plan says these services are not covered benefits.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 forthe topical application of fluoride -excluding varnish and oral hygiene instructions provided on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 14, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80307 and HCPCS G0483 remain 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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479)HCPCS G0483:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the records did not support the above denied codes. In addition, the records did not support an established relationship between the ordering physician and the enrollee. Review of claims history for this enrollee, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 11. However, the records indicate that the specimen was collected in an outpatient rehabilitation
setting, which would be indicated by POS code 57. This means that the claim was billed with the incorrect POS
code. Based on this information, we decided that Medicare rules for coverage of the services have not been
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 31,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic to be provided by a pharmacy.
You asked the Plan to pre-approve Ozempic. You say that you are appealing. The Plan denied your request.
The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare
Part B under the circumstances and the Plan does not administer the enrollee's Medicare Part D prescription
drug benefits.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Ozempic to be provided by a pharmacy.
Benefits for Ozempic 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says per the standard of care, the requested treatment 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 the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clear connection between the exam and the MRI imaging, showing nerve root impingement and corresponding radiculopathy. The criteria for the surgery is not met.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for drug test. You say that you were not aware of the prior authorization requirement.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 has network providers available who can provide 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 August 14, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on March 2, 2020.You asked the Plan to waive the copayment for the spinal injection. You say that you are being billed for charged other than your copayment. 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 $285 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $285copayment for the spinal injection. The spinal injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayment for the spinal injection provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene expression profile provided to the enrollee on August 27, 2019.
You asked the Plan to pay for the testing. You say that this definitive analysis was critical in determining the appropriate treatment assessment for the patient. The Plan denied your request. The Plan says this is a non-covered service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the testing at issue in this case was not medically reasonable or necessary. Our physician reviewer found the enrollee had a mildly elevated PSA. A DRE is not documented. There is no evidence that the enrollee had undergone an MRI or prostate biopsy. As such, the documentation does not support that the provided test was medically necessary, reasonable or coverable. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the oncology gene expression profile provided to the enrollee on August 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic services (CPT 27236) provided to the enrollee on September 14, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 27236-RT remains 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 CPT code 27236 is "open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided do not include documentation of an open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement being performed on September 14, 2019, 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 services have not been met. Therefore, we decided that the Plan does not have to pay for orthopedic services (CPT 27236) provided to the enrollee on September 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 30,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 has network providers
available who can provide the services 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 these services. Therefore, we decided that the
Plan does not have to pay for physician services provided to the enrollee on January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ablation procedure provided on December 13, 2019.
You asked the Plan to waive the copayment for the ablation procedure. You say that you should not be responsible for a surgery charge. You say you paid less the last time you had the ablation procedure. 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 $260 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $260 copayment for the ablation procedure. The ablation procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital facility.
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 copayment for the on December 13, 2019.