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

We decided that the Plan does not have to pay for the procedure codes billed 50949 and 52332.

You asked the Plan to pay for the procedure codes billed 50949 and 52332. You say that you would like these services reprocessed for payment. The Plan denied your request. The Plan says the services as billed are not supported in the medical records submitted.

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 50949 is Unlisted laparoscopy procedure, ureter. The CPT Code Manual definition of code 51999 is Unlisted laparoscopy procedure, bladder.

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 procedure codes billed 50949 and 52332. Our reviewer says that the medical records provided do not include sufficient documentation to indicate what procedures were performed. Our reviewer found when reporting a service that is rarely provided, unusual, variable, or new, the appropriate "Unlisted Procedure" code may be used to indicate the service, identifying it by "Special Report". Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. This information was not documented in the medical documentation submitted for either of the services provided. 

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 procedure codes billed 50949 and 52332 have not been met. Therefore, we decided that the Plan does not have to pay for the procedure codes billed 50949 and 52332.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on February 9, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of a relationship between the enrollee and the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.
We looked at the file and the rules. We find that the testing at issue is not supported in the medical records. In this case, there are insufficient records including a consultation to show the enrollee is being treated for a specific medical problem. 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 the lab testing services provided on February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the sacroplasty provided on December 4, 2020.
You asked the Plan to pay for percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed (0201T). You say that the enrollee with a history of sacral pain was not responding well to conservative management. The Plan denied your request. The Plan says the clinical value and effectiveness of sacroplasty in the setting of sacral fractures have not been demonstrated in the peer-reviewed literature.
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 percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed (0201T). Our reviewer says that the services were not considered medically reasonable and necessary in this case. Our physician reviewer found sacroplasty remains experimental. 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 percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed (0201T) have not been met. Therefore, we decided that the Plan does not have to pay for the sacroplasty provided on December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of the Intracept procedure in the setting of lumbar radiculopathy and lumbar degenerative disc disease have not been demonstrated in the peer-reviewed literature
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure to treat back pain. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life2000 Technologies non-invasive open ventilation system.
You asked the Plan to pre-approve oxygen equipment accessory. You say that the enrollee is unable to effectively ventilate, and this is the only one-pound wearable ventilator on the market. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this device is considered an oxygen equipment accessory and cannot be separately covered.
The Plan must follow Medicare rules. Medicare rules say that oxygen accessories are included in the allowance for rented oxygen equipment, so accessories will be denied as non-covered. We looked at the file and Medicare rules. This device is considered to be an oxygen equipment accessory. Although it may be appropriate for use by the enrollee, Medicare does not make separate coverage for this accessory. Based on this information, we decided that Medicare rules for coverage of oxygen equipment accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life2000 Technologies non-invasive open ventilation system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27236) provided to the enrollee on October 14, 2020.
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 the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27236 is "open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records submitted do not include documentation of an open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement being performed on October 14, 2020; 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 surgical services (27236) provided to the enrollee on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910), and an adjunctive pre-diagnostic test (D0431) provided on April 7, 2021.
You asked the Plan to pay for periodontal maintenance, and an adjunctive pre-diagnostic test. You say that the services were necessary and should be covered. The Plan denied your request. The Plan says the periodontal maintenance is a covered benefit, but you have exceeded the frequency limit of one every 12-month period. The adjunctive pre-diagnostic test 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance, and an adjunctive pre-diagnostic test have not been met. Specifically, the record shows that you had exceeded the frequency limit for periodontal maintenance prior to this service on July 22, 2020. Additionally, an adjunctive pre-diagnostic test is not a covered benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910), and an adjunctive pre-diagnostic test (D0431) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88361) provided to the enrollee on February 3, 2021.

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 the diagnosis code reported does not support medical necessity.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the test. The medical records from the date of service 02/03/2021 were reviewed and confirmed that the documentation showed the pathology claims are often billed on multiple claims for the same date of service. The review has determined that the services at issue in this case were 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88361) provided to the enrollee on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and crown
(D2740) provided on April 28, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray and crown. You say that you are on a fixed
income and the cost of these services is a hardship for you. The Plan denied your request. The Plan says these
services are not covered by 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. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray (D0220) and crown (D2740) provided on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 28, 2020.

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 the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records for the date of service in question. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on April 13, 2021.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and panoramic x-ray. You say that the services you received were advertised as being free upon the initial visit. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation (D0150) is limited to one procedure code every three years, and full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on April 1, 2021, and your comprehensive oral evaluation (D0150) and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on April 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 14, 2021. 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 the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain records for the date of service in question. Records were submitted for an exam on January 13, 2021. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 provided on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the two crowns (D2740 x2) provided on August 17, 2020.
You asked the Plan to pay more for the crowns. You say that your dentist did not receive any payment from the Plan, and you paid for these services out-of-pocket in full. The Plan denied your request. The Plan says you pay a 50% coinsurance for Class 3 Major Services.
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, you are responsible for a 50% coinsurance for Class 3 Major Services, including crowns. The Plan does not have to pay more than a 50% coinsurance for each crown. Therefore, we decided that the Plan does not have to pay more for the two crowns (D2740 x2) provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete root canal (D3332) provided on January 26, 2021.
You asked the Plan to pay for the dental service. You say that you were experiencing pain on the right side of your mouth. You say that the provider should be paid for the terminated service. You say that the crack was internal to the tooth and hidden by the crown and only became visible mid-process. The Plan denied your request. The Plan says incomplete root canal is not listed as a covered service.
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 for the incomplete root canal (D3332) provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by a non-participating
provider, Moffit Hematologist/Oncologist.
You asked the Plan to pre-approve the office visit. You say that you need a second opinion and you want the
best treatment so you can deal with this. The Plan denied your request. The Plan says there are multiple innetwork
specialists as well as tertiary providers available that can provide the requested services.
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
the office visit to be provided by a non-participating provider, Moffit Hematologist/Oncologist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services received on May 17, 2021 and May 27, 2021.
You asked the Plan to waive the copayment for the services. You say that the charges should be removed as your responsibility. The Plan denied your request. The Plan says enrollees are responsible for copayments.
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 $20 copayment for therapy services.
You have been asked to pay a $20 copayment for the services. The services fall within the therapy 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 physical therapy services received on May 17, 2021 and May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x2), and a fixed partial denture
sectioning (D9120) provided on April 14, 2021.
You asked the Plan to pay for extractions, and a fixed partial denture sectioning. You say that the services were
necessary. The Plan denied your request. The Plan says the extraction is a covered benefit, but you have
exceeded the frequency limit of one every year. The fixed partial denture sectioning 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of extractions, and a fixed partial denture sectioning have not been met. Specifically, the record
shows that you had exceeded the frequency limit for the extractions. Additionally, a fixed partial denture
sectioning is not a covered benefit. Therefore, we decided that the Plan does not have to pay for extractions
(D7210 x2), and a fixed partial denture sectioning (D9120) provided on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Keytruda is not FDA approved for the treatment of prostate cancer. NCCN support is as a single-agent for castration-resistant distant metastatic disease that is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) and with prior novel hormone therapy and no prior docetaxel. There is no MSI-H or dMMR provided. Off-label use is not supported by major drug compendia or the medical literature. the service is not 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee.