Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on April 7, 2021.
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 99233 was billed with place of service code 21, which indicates an inpatient hospital. The records provided do not indicate the enrollee was an inpatient at the time the services were provided. 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 evaluation and management services provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing and BART or large rearrangement analysis (genetic test for risk of breast or ovarian cancer) (CPT code 81162).
You asked the Plan to pre-approve the genetic testing. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. Medicare doesn't cover BRCA genetic testing if you don't have a personal history of breast, ovarian, or pancreatic cancer. It's considered to be screening and is specifically excluded by Medicare. The test at issue in this appeal, the genetic testing, is being 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 pre-approve comprehensive BRCA 1 and 2 testing and BART or large rearrangement analysis (genetic test for risk of breast or ovarian cancer) (CPT code 81162).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), provided on August 18, 2021.
You asked the Plan to pay for the crown. You say that the services should be covered. The Plan denied your request. The Plan says this is not 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 crown (D2740), provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on June 11, 2021 and billed under code 85060.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. The denied CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients. Review of the member's claim shows the provider billed in a place of service of 22 for Outpatient Hospital. The Plan states a corrected claim would be reviewed if submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an issue with the place of service code reported on the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on June 11, 2021 and billed under code 85060.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental pneumatic appliance for use with a pneumatic compressor (E0667 x 2) to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested items.  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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental pneumatic appliance for use with a pneumatic compressor (E0667 x 2) to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested service is experimental/investigational.
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 a Vertiflex procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate
the procedure's 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869).
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 the enrollee only requires short-term additional
acute care services that can safely be administered at the current facility. The enrollee does not require services
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered 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.
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH)
services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unspecified preventive service (D1999), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on July 20, 2021.  You asked the Plan to pay for the dental services. You say that the dental office did not discuss with you that they had checked with your insurance first. You say that this was a procedure that they just went ahead and did. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says the periapical x-rays are not listed as covered services. The Plan also says that the unspecified preventive service 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 periapical x-rays and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam CT capture (D0364) provided on June 11, 2021.  You asked the Plan to pay for the cone beam CT capture (D0364). You say that the doctor makes clear the necessity of the denied procedure and you are requesting reimbursement. The Plan denied your request. The Plan says the service 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 the cone beam CT capture (D0364) provided on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 74176 provided on May 31, 2021.

You asked the Plan to pay for the computed tomography. 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 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 the computed tomography is a column II code to column I code 74176 for 74177. 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 the computed tomography coded 74176 provided on May 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you had on May 18, 2021.  You asked the Plan to waive the copayment for the TTE. You say that you are on a fixed income and this additional charge was never discussed during your visit. 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 $125 copayment for diagnostic radiological services.   You have been asked to pay a $125 copayment for the TTE. The TTE falls within the diagnostic radiological 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 the transthoracic echocardiography (TTE) you had on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mobile imaging services provided on August 16, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately payable.  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. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. 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 mobile imaging services provided on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on July 26, 2021.  You asked the Plan to pay for the computed tomography. 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 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 70450 for the computed tomography is a column II code to column I code 70496. 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 the computed tomography coded 70450 provided on July 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychiatric services provided on November 6, 2020, to May 7, 2021, by an out-of-network provider.  You asked the Plan to pay for psychiatric services. You say that the services at issue were a necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 psychiatric services provided on November 6, 2020, to May 7, 2021, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on May 23, 2021, through June 8, 2021.

You asked the Plan to pay for the SNF care. You say that the service should be covered. The Plan denied your request. The Plan says the benefit has been exhausted.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit periods from January 7, 2021, through January 16, 2021, January 20, 2021, through February 5, 2021, April 12, 2021, through May 22, 2021, and July 12, 2021, through August 21, 2021. The Plan has covered 100 days of SNF care. 

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on May 23, 2021, through June 8, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve 4 MBB procedures. We decided that the Plan does not have to pre-
approve 2 MBB procedures.
You asked the Plan to pre-approve 6 MBB procedures. You say that the requested services are a medical
necessity for the enrollee. The Plan says that medical necessity rules for the requested services have not been
met.
We decided that the Plan has to pre-approve 4 MBB procedures.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically
reasonable and necessary in patients who meet all the criteria listed in the Medicare rules section of this letter.
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 6 MBB procedures. Our reviewer says
that an MBB procedure at 4 joints (2 levels bilaterally) is medically reasonable and necessary in this case. Our
physician reviewer found that, since it has been greater than 2 years, the process of dual diagnostic MBBs
needs to be repeated as per the Medicare rules. Further, the rules limit the number of joints to 4 per session, so
only 2 levels bilaterally per session. The enrollee does not need to trial physical therapy again. The request
meets the criteria for diagnostic MBBs of only 4 joints, 2 levels bilaterally.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 6 MBB procedures have been met. Therefore, we decided that the Plan has to
pre-approve 4 MBB procedures.
We also decided that the Plan does not have to pre-approve 2 MBB procedures.
The Plan follows Medicare rules. Medicare rules say limit the number of joints to 4 per session. Based on this
information, we decided that Medicare rules for coverage of 2 MBB procedures have not been met. Therefore,
we decided that the Plan does not have to pre-approve 2 MBB procedures.
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) coded 95957, the nerve conduction studies coded 95910, and the needle electromyography coded 95886 provided on January 6, 2021.

You asked the Plan to pay for the digital analysis of electroencephalogram (EEG), the nerve conduction studies, and the needle electromyography. 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 95957, 95910, and 95886 are not supported in the medical record. Specifically, the technical report did not include documentation of digital analysis of an electroencephalogram (EEG) (for epileptic spike analysis); therefore, code 95957 cannot be verified. The technical report did not include documentation of nerve conduction studies, for 7-8 studies; therefore, code 95910 cannot be verified. The technical report did not include documentation of a complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. 

Based on this information, we decided that Medicare rules for coverage of the digital analysis of electroencephalogram (EEG), the nerve conduction studies, and the needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) coded 95957, the nerve conduction studies coded 95910, and the needle electromyography coded 95886 provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical extraction (D7210) and bone replacement graft
(D7953), provided on July 8, 2021.
You asked the Plan to pay for a surgical extraction and bone replacement graft. You say that the services
should be covered. The Plan denied your request. The Plan says the correct cost share was applied for the
extraction and bone grafts are not covered benefits.
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 surgical extraction (D7210) and bone
replacement graft (D7953), provided on July 8, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee for surgery on May 5, 2021.
You asked the Plan to pay for this claim. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says this claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary.
The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee for surgery on May 5, 2021.