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

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) (testing by use of individual test CPT codes or CPT 81455) provided on September 12, 2020, by a non-participating provider.

You asked the Plan to pay for the testing. You say that the service was medically necessary. The Plan denied your request. The Plan says as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) (testing by use of individual test CPT codes or CPT 81455) provided on September 12, 2020, by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided on August 26, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewing x-rays, and prophylaxis. You say that you were told by the dental office before the appointment that they took your insurance and that the services would be covered. The Plan denied your request. The Plan says the services were rendered by an OON provider.

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 covered when they are received OON. The record shows that on February 6, 2020 you were informed by a Plan representative that this provider was not a contracted provider with the Plan, and that your plan has no OON benefits. The Plan says that you were referred to dentists in your area that could treat you. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided on August 26, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95937).

You asked the Plan to pay for the train of four monitoring. 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 service 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.

In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.

We find that CPT code 95937 is not supported in the record. Specifically, neuromuscular junction testing has not been documented. Additionally, train of four monitoring is considered integral to the primary procedure and is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95937).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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 relevant Medicare 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. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99213) provided September 22, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the right diagnosis code was not reported.

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 99213 is not supported in the medical record. Specifically, some diagnosis codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific code is available. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99213) provided September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0648) provided October 2, 2020.

You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery. No itemized shipping receipt was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L0648) provided October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01214) and an anesthesia injection (64450).

You asked the Plan to pay for anesthesia and an anesthesia injection. You say that these services were billed correctly. The Plan denied your request. The Plan says these codes are not supported in the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 01214 is anesthesia for open procedures involving hip joint; total hip arthroplasty. The definition of 64450 is injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch.

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 anesthesia and an anesthesia injection. Our reviewer says that these codes are not supported in the records. Our physician reviewer found the medical records provided do not include sufficient documentation to corroborate that anesthesia for open procedures involving hip joint; total hip arthroplasty was performed, therefore 01214 service cannot be verified. There is no operative note of a hip arthroplasty included in the medical records submitted. Per NCCI edits, 64450 is bundled with billed procedure 01214. The medical records provided do not include sufficient documentation to validate 64450 as a separately identifiable service, therefore it would be included in reimbursement for CPT 01214. Since 01214 was deemed not eligible for reimbursement, there is no separate allowed reimbursement for 64450.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia and an anesthesia injection have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01214) and an anesthesia injection (64450).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyalgan injection (J7321).

You asked the Plan to pre-approve Hyalgan. You say that the enrollee has trialed Visco-3. The Plan denied your request. The Plan says rules for pre-approval have not been met.

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 Hyalgan. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that, based on the documentation provided, the provider appears to have attributed the enrollee's right knee swelling to a reaction to the prior Visco-3 injections. As such, further use of Sodium hyaluronate, even if a different name brand, is contraindicated. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hyalgan injection (J7321).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on April 22, 2020, through April 28, 2020.

You asked the Plan to pay for the critical care services. 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 include the amount of time spent providing critical care services.

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 record. Specifically, the documentation submitted does not include the amount of time spent rendering the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on April 22, 2020, through April 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 10, 2019.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you were given the wrong information. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $200 copayment for ambulance services. 

You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on June 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the eyeglass frames (V2020) rendered by the out of network (OON) provider.

You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the eyeglass frames 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to issue reimbursement for the eyeglass frames (V2020) rendered by the out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax, diagnostic; with contrast material(s) (CPT Code 71260).

You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says the criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the CT scan. Our physician reviewer found the review indicates that according to the NCCN guidelines, stage I tumors are routinely followed with history and physical every three to six months for two to three years and then annually. Chest imaging is recommended every six to twelve months by Computed tomography (preferred) or x-ray. (page MS-21, discussion section from NCCN guidelines version 1.2021 soft tissue sarcoma of the extremities, superficial trunk or head and neck). For surveillance purposes, there is very limited data on the frequency of imaging. Because of the overall stability of prior Computed tomography chest findings, there is reason to consider Computed tomography scan imaging every six to twelve months. The review has determined that the requested CT scan is not medically reasonable or 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax, diagnostic; with contrast material(s) (CPT Code 71260).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a 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 with neurogenic claudication and chronic low back pain. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the requested Vertiflex device is not medically necessary 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS).

You asked the Plan to pre-approve the services. You say that the goal is to help alleviate pain. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not covered. 

The requested stimulation is acupuncture for stimulation of auricular points. Additionally, the service was billed with CPT 64555, which is incorrect coding. 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 pre-approve percutaneous electrical nerve stimulation (PENS).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this request is considered experimental and 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for the treatment of low back pain. More research is needed to show safety and efficacy. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient level of care for the approved surgery.

You asked the Plan to pre-approve an inpatient level of care for the approved surgery. You say that the inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. The Plan says that the inpatient level of care for the approved surgery is not medically necessary.

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 an inpatient level of care for the approved surgery. Our reviewer says that the inpatient level of care for the approved surgery is medically necessary. Our physician reviewer found the medical records indicate that the enrollee is having extensive multilevel spinal fusion surgery. The plan has approved the procedure as an outpatient. This is an extensive and complex surgery over multiple levels of the spine. Bleeding and operative times are high. An inpatient level of care is 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 an inpatient level of care for the approved surgery have been met. Therefore, we decided that the Plan has to pre-approve an inpatient level of care for the approved surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services with dental codes D6751 and D6251.

You asked the Plan to pre-approve dental codes D6751 and D6251. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested dental services are not covered under the Plan's supplemental dental 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, dental codes D6751 and D6251 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the dental services with dental codes D6751 and D6251.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.

You asked the Plan to pre-approve these services. You say that you don't want to drive two hours to the network provider. The Plan denied your request. The Plan says the services are available from network providers.

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 a referral to an out-of-network orthopedic surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7410).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve dental services (D7410).