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

We decided that the Plan does not have to pay for an additional unit of mammography services (77063, 77067) provided on April 8, 2021.
You asked the Plan to pay for mammography services. You say that the enrollee had multiple exams on this date. The Plan denied your request. The Plan says additional units are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that an additional unit each of CPT codes 77063 and 77067 are not supported in the medical record. The medical record only supports one unit each of CPT codes 77063 and 77067. Based on this information, we decided that Medicare rules for coverage of mammography services have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of mammography services (77063, 77067) provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on April 21, 2021.

You asked the Plan to pay for the services provided. You say that you have no knowledge of patient coverage
prior to the specimen's arrival. The Plan denied your request. The Plan says the billed services cannot be
verified.

The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician
who is treating the beneficiary.

We find that the comprehensive gene panel is not supported in the medical record. The case file shows that the
testing at issue was not ordered by the physician listed on the requisition. Tests not ordered by the physician
who is treating the beneficiary are not reasonable and necessary. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the genetic testing services provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 25, 2020.

You asked the Plan to pay for the services provided. You say that you received a referral for a provider that was in your network. The Plan denied your request. The Plan says the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The file shows that oral hygiene instructions, topical application of fluoride varnish, pulpal debridement, a periodontal procedure, drugs dispensed in office, and a dental bridge were provided.

Although 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 dental services provided on June 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with an inappropriate primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with only one diagnosis code, I26.90 (Septic pulmonary embolism without acute cor pulmonale). This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology 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 services provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related
accessory (E0673) provided September 14, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says these items are not
covered.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of peripheral artery disease is not covered and will be denied as not reasonable and necessary. Related
accessories are eligible for reimbursement only when the related base PCD is covered.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. In addition, the related
accessory will not be covered when the base has been denied. Therefore, we decided that the Plan does not
have to pay for a pneumatic compression device (E0675) and related accessory (E0673) provided September
14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1852).
You asked the Plan to pre-approve the orthosis. You say that at your age you are concerned regarding surgery and have wanted to try physical therapy and a brace. You are very unsteady and afraid of falling and causing worse damage. The Plan denied your request. The Plan says this request is not medically necessary because the records do not show the enrollee has had recent injury or surgery or objective evidence of instability.
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee without recent surgery or injury. The documented physical examination does not demonstrate instability of the knee. The elements of the coverage rule are not satisfied, and the requested service cannot be recommended. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1852).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cardiology office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the cardiology office visit. You say that you have been seen by the in-network provider. The Plan denied your request. The Plan says the provider is out-of-network

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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the cardiology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic injection rendered on October 30, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 64415 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 64415 (anesthetic injection) and 01638 (anesthesia for shoulder replacement). Code 644153 is a column II code with a modifier indicator of 1 when billed with column I code 01638. Code 64415 was not billed with an appropriate modifier to allow for separate payment.

Therefore, we decided that the Plan does not have to pay for the anesthetic injection rendered on October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 26, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that the services should be covered. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. The intraoral complete series of radiographic images 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 a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on January 14, 2019. Additionally, an intraoral complete series of radiographic images is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 18, 2020.
You asked the Plan to pay for the lab 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 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. 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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be still somewhat unstable with persistent low grade fever and requires additional short-term acute care services which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into and LTACH is not medically
necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there was surgery of the hand, not surgery of the knee.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 and the advance care planning services coded 99497 provided on January 10, 2021.

You asked the Plan to pay for the initial hospital care services and the advance care planning services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 codes 99223 and 99497 are not supported in the medical record. Specifically, the documentation does not support a comprehensive history, comprehensive examination, medical decision making of high complexity to support the billing of code 99223. In addition, the documentation does not support advance care planning including the explanation and discussion of advance directives to support the billing of code 99497. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services and the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 and the advance care planning services coded 99497 provided on January 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95999 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 16, 2021.
You asked the Plan to pay for the office visit. You say that the doctor's office will not do any insurance billing. The Plan denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The file shows that you received a new patient visit. In this case, code 99206 is not a valid code eligible for payment. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 4,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this provider will be your new
primary care physician and you thought that this would be considered a primary care visit. 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 $35
copayment for specialist visits.
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on November 6, 2020 to November 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 99233, 99291, and 99214 are 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 99233 is Level 3 subsequent hospital care for evaluation and management of patient, including detailed interval history and medical decision making of moderate complexity, typical time 35 minutes. The definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. The definition of code 99214 is Outpatient visit for evaluation and management of established patient, including medically appropriate examination and
moderate level of medical decision making, total time 30-39 minutes. We find that CPT codes 99233, 99291, and 99214 are not supported in the medical record. Specifically, there is no documentation of Level 3 subsequent hospital care for 35 minutes to support code 99233. There is no documentation of critical care for 30-74 minutes to support code 99291. There is no documentation of an office visit for 30-39 minutes to support code 99214. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on November 6, 2020 to November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) provided on April 1, 2021.

You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed the need for the billed supply code.

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 relevant medical records which support medical necessity for the supplies provided in this case. The records do not show the referring physician discussed the need for a CGM. 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 the supply allowance for therapeutic continuous glucose monitor (CGM) provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206 provided on March 15, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 81206 is not supported in the medical record. Specifically, the services rendered should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the comment/narrative field for the test. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206 provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).

You asked the Plan to pre-approve the denture. You say that the front teeth of the current denture have broken
off. The Plan denied your request. The Plan says the benefit has been exhausted.

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 dentures once
every five years.

The file shows that the same services were last received on July 16, 2017, which is less than five years (sixty
months) ago. Based on this information, we decided that the Plan's rules for coverage of the denture have not
been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture
(D5213).