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

We decided that the Plan does not have to pay for placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance (CPT code 19283 XE LT) provided to the enrollee on June 30, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says CPT code 19283 XE LT is identified as a device intensive procedure that was not reported with a device CPT code on the claim required for that procedure.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. We reviewed the I/OCE Specifications file for this date of service. OCE edit 92 is invoked when "A device-intensive procedure is reported without a device code. See Device Intensive Procedure Editing and Processing for more information." The required disposition for a claim with this edit is for the claim to be returned to the provider. Per this file, "If the claim is returned to the provider for failure to pass the edit, the hospital will need to modify the claim by either correcting the device code or ensuring that one of the required procedure codes is on the claim before resubmission." Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance (CPT code 19283 XE LT) provided to the enrollee on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for intraoral procedures, including biopsy (CPT
code 00170) provided to the enrollee on May 6, 2021.

You asked the Plan to pay for the service. You say that the enrollee has coverage for this dental service. The
Plan denied your request. The Plan says the service is not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

Regardless of whether the inpatient hospital services are covered, the medical services of physicians furnished
in connection with noncovered dental services are not covered. The services of an anesthesiologist, radiologist,
or pathologist whose services are performed in connection with the care, treatment, filling, removal, or
replacement of teeth or structures directly supporting teeth are not covered. This means that while the inpatient
facility claim may be payable, the professional claim is not payable because tooth extractions are not a
Medicare-covered service. Therefore, we decided that the Plan does not have to pay for anesthesia for intraoral
procedures, including biopsy (CPT code 00170) provided to the enrollee on May 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the dialysis services provided on February 12, 2021.

You asked the Plan to pay for the dialysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file has conflicting documentation. The documentation both shows that the claim was denied due to being provided by an out of network provider but also states that claim was denied due to a valid or more specific diagnosis, procedure, revenue, DRG, or Healthcare Common Procedure Code (HCPC) needed before this claim can be considered for payment. This means there is no clear reasoning as to why this claim was denied. The Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the dialysis services provided on February 12, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health services you received from December 31, 2020, to January 8, 2021.
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you think this should be adjusted. You said that you were billed for seeing a psychiatrist seven times, but you only met with a psychiatrist twice. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per day for days 1-5, and a $0 copayment for additional days for inpatient mental health care.
Records show that you received inpatient mental health care for nine days. You were charged a $200 copayment per day for each of the first five days, for a total of $1000. You were not charged a copayment for the remaining days. This copayment applies regardless of how many times you see a psychiatrist during your stay. 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 inpatient mental health services you received from December 31, 2020, to January 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar arthrodsis.

You asked the Plan to pre-approve lumbar arthrodsis. You say that the proposed interlaminar fixation with Stabilink is the most appropriate form of treatment. You say that the enrollee meets the covered indications. The Plan denied your request. The Plan says the procedure has not been medically proven to be effective.

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 lumbar arthrodsis. Our reviewer says that lumbar arthrodsis is not considered medically reasonable and necessary in this case. Our physician reviewer found the Stabilink device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar arthrodsis have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar arthrodsis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only (CPT code E2375) provided to the enrollee on October 29, 2020.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the billed code is not eligible for billing with modifier NU and is only payable as a rental.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

You billed code E2375 as a new purchase. Per article MM8822, this code is only payable as rental equipment. As a result, E2375 cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for power
wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only (CPT code E2375) provided to the enrollee on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT)code 83789-59) provided to the enrollee on April 25, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this code is included in CPT code 80307 and G0480; therefore, it cannot be separately reimbursed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 83789-59 (1 Unit) remains not supported. Documentation does not support the comprehensive procedure code G0480 and 80307. Since there is a CCI conflict between G0480, 80307 and 83789 we cannot review the component code 83789 nor the use of modifier 59. This code is included in CPT code 80307 and G0480; therefore, it cannot be separately reimbursed. This code is not separately reimbursed when billed for specimen validity testing on urine specimens utilized for drug testing. Therefore, we decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT)code 83789-59) provided to the enrollee on April 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Cxbladder Detect test (CPT code 0012M) provided to the
enrollee on June 9, 2021.

You asked the Plan to pay for the test. You say that the test should be covered. The Plan denied your request.
The Plan says the test is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the test have not been met. The rules say non-coverage reaffirmed
for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for
Cxbladder Detect test (CPT code 0012M) provided to the enrollee on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and testing to be provided by an out-of-network provider.
You asked the Plan to pre-approve an office visit and testing to be provided by an OON provider. You say that the requested office visit and testing to be provided by an out-of-network provider is medically necessary. The Plan denied your request. The Plan says the requested office visit and testing to be provided by an out-of-network provider is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an office visit and testing to be provided by an OON provider. Our reviewer says that the requested office visit and testing to be provided by an out-of-network provider is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is not currently receiving any active treatment and/or medical management of her condition that makes it medically necessary for the enrollee to continue care with the requested OON provider. There is nothing unique about this enrollee's condition that would make it medically necessary for her to continue care with the requested OON provider. The Plan has shown that they have in-network providers who have the qualification and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. This enrollee's medical management and/or follow-up care can be safely transitioned to an in-network specialist at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit and testing to be provided by an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit and testing to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided May 12, 2021.

You asked the Plan to pay for sedation services. You say that the records provided support the necessity of the
services in dispute. The Plan denied your request. The Plan says place of service inappropriate for procedure.

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 99153 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; each additional 15 minutes intra-service time (list
separately in addition to code for primary service)

We find that CPT code 99153 is not supported in the medical record. Specifically, CPT 99153 has no physician
work associated with it and is therefore a technical component only code (PC/TC indicator 3). When billed in a
facility setting it is not payable to the physician but may be paid to the facility. When billed in the office it is
payable to the physician. Based on this information, we decided that Medicare rules for coverage of sedation
services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation
services (99153) provided May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (CPT code 99072) provided to the enrollee on June 29, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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, CPT code 99072, which has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment is made per Medicare. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (CPT code 99072) provided to the enrollee on June 29, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 13, 2021.

You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496.

This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (CPT code E0676) provided to the enrollee on January 20, 2021.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and hospital and outside providers. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (CPT code E0676) provided to the enrollee on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.

You asked the Plan to pre-approve Dupixent. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says Dupixent is on the self-administered drug list and is excluded from coverage under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.

Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Taltz injector.

You asked the Plan to pre-approve self-administered drug. You say that this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Taltz injector.

Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic services and an injection provided on June 30, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for orthopedic services and an injection. You say that you were referred by your primary care provider for urgent treatment. The Plan denied your request. The Plan says your referral was denied. The Plan also says that you were redirected to an in-network provider.

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 had network providers available who could have provided 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 for orthopedic services and an injection provided on June 30, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on April 2, 2021.

You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The targeted genomic sequence analysis panel at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on April 2, 2021.
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 based on the documentation provided there is no evidence that you require services
that are not currently available at the present setting where you are receiving care. You can remain at the
current setting until such time no acute services are required. You can then be transferred to 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.