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

We decided that the Plan does not have to pay for the services (63055, 20926) provided on July 16, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified. 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 63055 is "Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic". The CPT Code Manual definition of code 20926 is "Tissue grafts, other (eg, paratenon, fat, dermis)". 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 use of CPT codes 63055 and 20926 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of a Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic being performed on July 16, 2019. The medical records provided also do not include documentation that Tissue grafts, other (eg, paratenon, fat, dermis) were performed on July 16, 2019, therefore, these services cannot be validated. 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 the services (63055, 20926) provided on July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment identified by procedure codes L5685, L5679, L8417, and L8420.
You asked the Plan to pay for the durable medical equipment (DME). You say that the claims should be paid. The Plan denied your request. The Plan says documentation submitted did not include a valid physician order including a detailed description of the item ordered that meets all of the requirements of the billed HCPCS code; therefore, the billed service cannot be verified.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The documentation submitted did not include a valid physician order including a detailed description of the item ordered that meets all of the requirements of the billed HCPCS code; therefore, the billed service cannot be verified. Therefore, we decided that the Plan does not have to pay for durable medical equipment identified by procedure codes L5685, L5679, L8417, and L8420.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood count (85025) and chemotherapy administration (96413 and 96417) provided on October 22, 2019.You asked the Plan to pay for the blood count and chemotherapy administration. You say that you would like reconsideration basedon the records submitted. The Plan denied your request. The Plan says the record does not support the services that have been 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 blood count and chemotherapy administration.. Our reviewer says that CPT code 85025 does not meet criteria for billing or reimbursement consideration. CPT code 85025 is a CLIA waived test and does require a QW modifier to evaluate the claim to determine eligibility for benefit coverage of the laboratory service performed. Our reviewer found CPT codes 96413 and 96417 do not meet criteria for billing or reimbursement consideration.  The medical records provided do not include an infusion "start" and "stop" time to validate that Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug was performed and met Medicare guidelines, therefore, CPT 96413 is not eligible for reimbursement consideration. Additionally, CPT code 96417 is an add-on code and requires the primary code (96413) that was performed on October 22, 2019 to be eligible for reimbursement. In this case, CPT 96413 was denied, therefore, rendering CPT 96417 ineligible for reimbursement consideration. 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 blood count and chemotherapy administration. have not been met. Therefore, we decided that the Plan does not have to pay for a blood count (85025) and chemotherapy administration (96413 and 96417) provided on October 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95907) provided on February 13,
2019.
You asked the Plan to pay for the nerve conduction studies. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not
include interpretation and report to indicate that nerve conduction studies; 1-2 studies was performed.
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 95907 is nerve conduction studies; 1-2 studies.
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 nerve conduction studies. Our reviewer says that CPT
code 95907 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do in include in interpretation and report to validate that a Nerve conduction studies; 1-2
studies was performed on February 13, 2019, therefore, the service cannot be verified.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 16, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on October 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 17, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 did not pre-approve the
services 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's services provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient rehabilitation services provided from September 3, 2019 to September 26, 2019.
You asked the Plan to pay for the outpatient rehabilitation 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. Medicare says that CORF services are billed with bill type 075x. The file does not show that the claim was billed with the correct type of bill code. Based on this information, we decided that Medicare rules for coverage of the outpatient rehabilitation services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient rehabilitation services provided from September 3, 2019 to September 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electrocardiogram (93010) provided October 31, 2019.
You asked the Plan to pay for the electrocardiogram. You say that the services was medically necessary. The Plan denied your request. The Plan says none of the documentation provided has been authenticated by the rendering physician.
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 93010 is not supported in the medical record. Specifically, the claim form submitted notes as the rendering physician. The Medical records for the service at issue are signed by multiple physicians but none are signed or otherwise authenticated by the rendering provided listed on the claim form. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an Electrocardiogram (93010) provided October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from November 9, 2019 to November 16, 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 this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy (HCPCS S9328) provided to the enrollee from November 9, 2019 to November 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on October 8, 2019.

You asked the Plan to pay for the dental services. You say that your EOC states that one (1) dental x-ray is covered. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.

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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on October 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that SNF services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on December 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician 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 received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 forthe physician services provided on December 27, 2019 by an out ofnetwork (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 20. You asked the Plan to pre-approve the dental service. You say that the enrollee's tooth # 20 is periodontally stable. You say that tooth # 20 has more than 60% bone support. You say that the relation of crown to root is in favor of the stability of the tooth. The Plan denied your request. The Plan says that the crown for tooth # 20 is not medically necessary. The Plan also says there is less than 50% bone support.
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 dental service 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 dental service. Our reviewer says that the requested dental service is medically necessary. The supplied information reveals mild to moderate bone loss not exceeding 40%. The reviewer found that the tooth had been previously prepared for a crown or has required a temporary crown by the time the x-ray was taken. The reviewer found that the x-ray shows there is greater than a 1:1 crown to root ratio and that this tooth would be a viable abutment for a lower partial denture. As this tooth presents, there is no other method of restoration as the structure is shaped for a crown. The documentation shows there are no remaining cusps and no other method of restoration possible. Given the current presentation of tooth #20, with more than 50% remaining bone support and no other method of restoration possible, the reviewer found that the requested crown is medical reasonable and necessary. 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 dental service have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth # 20.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued in-home physical and occupational therapy (PT/OT) and home health aide (HHA) visits.
You asked the Plan to pre-approve the continued home health services. You say that the enrollee has made progress with her skilled therapy and needs continued visits to maintain her level of function. The Plan denied your request. The Plan says the enrollee's condition no longer requires skilled services to be provided in the home.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued home health services. Our reviewer says that the documentation does not support the medical necessity of ongoing home health services. Our physician reviewer found the records do not show that continued skilled physical and occupational therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient. The patient has been trained in a home exercise program (HEP). The
patient's functional level does not require the ongoing professional skills of a therapist for her condition. The patient and her granddaughter were educated in wound care. As the request for skilled therapies are not medically necessary the request for home health aide services are not medically necessary per Section 50.2 or for the treatment of the patient's illness or injury by the skilled professional staff. 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 continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued in-home physical and occupational therapy (PT/OT) and home health aide (HHA) visits.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Supartz FX.
You asked the Plan to pre-approve Supartz FX. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Supartz FX.
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 Supartz FX. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Supartz FX. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation submitted does not show that these drugs would likely be less effective and/or 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 Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Supartz FX.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you suffered a medical emergency that required your husband to call 911. You say that upon arrival, the EMT responders found that your blood sugar levels had fallen extremely low and immediately treated you. You began to recover and you say that no further treatment was required. You say that you do not understand why the claim was denied and that it should be reconsidered by the Plan. 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 October 17, 2019. 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 for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implants (D6010 x 4), the lower partial denture (D5212), the special supplies and materials (99070), the bone graft at time of implant placement (D6104), the prefabricated abutments (D6056 x 4), the abutment supported crowns (D6058 x 2), and the retainer crowns (D6740 x 2) provided on May 15, 2019.
You asked the Plan to pay for the dental services. You say that the services that you received were medical in nature. You say that in February 2018 you were diagnosed with Tetanus. You say that you had seizures and your teeth were fractured. You say that you had to have 6 teeth removed as a result. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan also says that implant related dental services are routine in nature and are not covered under your medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for 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 pay for the endosteal implants (D6010 x 4), the lower partial denture (D5212), the special supplies and materials (99070), the bone graft at time of implant placement (D6104), the prefabricated abutments (D6056 x 4), the abutment supported crowns (D6058 x 2), and the retainer crowns (D6740 x 2) provided on May 15, 2019.