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

We decided that the Plan does not have to pre-approve continuation of SNF care from August 28, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that you are ninety-five (95) years old and have a
shattered left hip and require additional inpatient coverage for therapy. The Plan denied your request. The Plan
says you no longer require skilled services and the continuation of SNF is 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 in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you no longer qualifies for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily
skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from August 28, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 7, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

We looked at the file and Medicare rules. It is inappropriate to bill an unspecified diagnosis code when there is a more specific code available. In this case, an unspecified diagnosis code was billed, however, there is a left-sided diagnosis code that would be more appropriate. 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 April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on April 15, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue 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 pay for a comprehensive periodontal evaluation (D0180) provided on April 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided March 16, 2021, to March 23, 2021.
You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says SNF care was not medically necessary and reasonable.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee no longer qualified for SNF coverage after March 15, 2021, based on the documentation provided. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs were custodial and, as a practical matter, could be provided at a lower 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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided March 16, 2021, to March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the procedure codes billed as 22612 and 63048x4.
You asked the Plan to pay for 22612 and 63048x4. You say that you would like these claims reprocessed for payment. The Plan denied your request. The Plan says the billed procedure codes 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 22612 is arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) and 63048x4 is Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure).
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 22612 and 63048x4. Our reviewer says that the documentation submitted does not support the services as billed. Our reviewer found the medical records provided do not include sufficient documentation to support separate reimbursement for the code billed 22612, Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) for date of service December 7, 2020. This service would be considered inclusive to the primary procedure performed. In addition, the medical records submitted do not include sufficient documentation to support code 63048x4 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar were performed. Therefore, this procedure 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 22612 and 63048x4 have not been met. Therefore, we decided that the Plan does not have to pay for the procedure codes billed as 22612 and 63048x4.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816,
78815, 78814, 78812, 78811, 78813).
You asked the Plan to pay for the diagnostic service. You say that you are requeting a repeat PET/CT to
evaluate for response to therapy and resolution of uptake in thoracic aorta. The Plan denied your request. The
Plan says it is not medically necessary to use this test for the enrollee's condition. There are other tests (CTA or
MRA) that might be helpful.
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the previous PET/CT scan that was performed on September 30, 2020, was approved regarding his suspicion for subclavian stenosis and large vessel vasculitis. Because of findings in other imaging, and elevated lab reports, this was a unique circumstance that allowed for an exception to the criteria. The current request is to evaluate if treatment has been effective, and the PET/CT scan is not listed as an approved imaging test for vasculitis. The requested PET scan is not medically necessary for this 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 the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization imaging (78816, 78815, 78814, 78812, 78811, 78813).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance, for a therapeutic continuous glucose monitor, provided on February 26, 2021. You asked the Plan to pay for the supply allowance for a therapeutic continuous glucose monitor (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition, nor did it indicate the provider discussed the need, for the billed supply code. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The medical record of the office visit on April 12, 2021 does not show that the enrollee uses a CGM or that the physician discussed a CGM. Based on this information, we decided that Medicare rules for coverage of the supply allowance for therapeutic continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance, for a therapeutic continuous glucose monitor, provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular radiofrequency ablation services provided on October 26, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the clinical effectiveness of the procedure for knee pain has not been demonstrated.

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 provided. Our physician reviewer found that this is an experimental/investigational procedure that is the subject of ongoing clinical trials. The patient was not enrolled in a clinical trial. Therefore, the request is considered 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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the genicular radiofrequency ablation services provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 4, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 3, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided on
December 31, 2020.
You asked the Plan to pay for an emergency room visit. You say that these services are supported in the
records. The Plan denied your request. The Plan says these services are not separately payable.
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, we have confirmed that code 99285
has a bundled relationship with code 99291 and code 93010 has a bundled relationship with code 36556 and
cannot be paid as billed. These codes cannot be paid as a separate line item. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an
emergency room visit (99285, 93010) provided on December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is not 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any documented skilled nursing or skilled therapy needs. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee orthosis (L1851).
You asked the Plan to pre-approve the orthosis. You say that the enrollee will benefit functionally from the use of the device over the course of their treatment plan. The Plan denied your request. The Plan says the records do not show that the enrollee meets the Medicare criteria and requested knee brace is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding recent injury or a surgical procedure on the knee. Knee instability is not documented on exam. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for knee orthosis (L1851) 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve knee orthosis (L1851).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81401) provided on January 12, 2021. You asked the Plan to pay for a pharmacogenetic panel. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed 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. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. We find that CPT codes 81225, 81226, and 81401 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81401) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (23430) provided on February 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code.
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, we have confirmed that code 23430 has a bundled relationship with code 23472 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (23430) provided on February 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services received on March 19, 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 you are responsible for the copayment.
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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for the services. the services falls 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 pay for ambulance services received on March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant at surgery services provided on December 8, 2020.
You asked the Plan to pay for the laparoscopy (43644) assistant at surgery services. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says the provider is listed by Medicare as a Specialist/Technologist.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for intraoral procedures provided on
December 28, 2020.
You asked the Plan to pay for the anesthesia for intraoral procedures. You say that you were never told you
needed a predetermination and you need help expediting your claim. The Plan denied your request. The Plan
says the service is not a covered benefit.
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 anesthesia for intraoral
procedures provided on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 25, 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 the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. 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 laboratory services rendered on October 25, 2020.