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

We decided that the Plan does not have to pay for the neuromonitoring services provided on April 29, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 95907 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE.
The Plan must follow Medicare rules. Medicare rules say that for bundled procedures, payment for covered services is always bundled into payment for other services not specified. We find that CPT code A4556 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident.
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 95885 is not supported in the medical records. There is a more comprehensive code available for the free running electromyography 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 neuromonitoring services provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve compression stockings. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel provided on July 20, 2021.
You asked the Plan to pay for the services provided. You say that the testing will guide appropriate medical
management. The Plan denied your request. The Plan says the services must be billed with a single 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.
We looked at the file and the rules. The claim information shows that the gene panel was billed with multiple
codes. If a single procedure is performed, only one code with one unit of service may be reported for the
procedure. 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 Tempus gene panel
provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on September 14, 2021.
You asked the Plan to pay for the limited exam. You say that this was a follow up for a previous exam and was medically necessary. The Plan denied your request. The Plan says limited oral evaluations may only be covered once per year. You had a previous limited exam on September 9, 2021, which was covered at that time. Therefore, the limited exam provided on the date in question exceeds the frequency limitations of your dental 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. The Plan can cover one limited exam to evaluate a
problem (D0140) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the exam is requested in a frequency
that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited
oral exam (D0140) provided on September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0427) provided on September 13, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were provided
with the wrong prescription, which caused these services to be medically necessary. The Plan denied your
request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance
with your contract. Your quality-of-care concern is being addressed in a separate grievance case; however,
waiving copayments for services which were provided is not part of this process.
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 $225
copayment for each one-way ambulance trip.
You have been asked to pay a $225 copayment for the ambulance transportation. 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 ambulance transportation services (A0427) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the deep sedation provided on September 16, 2021.  You asked the Plan to pay for the deep sedation. You say that your regular dentist and this provider were not able to extract the teeth with normal medication. You say that the extractions could not have happened without the anesthesia and payment should be reconsidered. The Plan denied your request. The Plan says that general anesthesia and intravenous sedation are excluded from coverage.  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. The Plan denied the deep sedation because the dentist informed you some services may not be covered. The Notice of Medicare Non-Coverage submitted is not adequate notice that the deep sedation may not be covered. Your Dental Contract clearly says that general anesthesia and deep sedation is covered for surgical procedures or restorative dentistry. The Plan did not submit sufficient documentation to support that you received notice the deep sedation would not be covered or that the deep sedation was not medically necessary for the surgical extractions. Therefore, we decided that the Plan has to pay for the deep sedation provided on September 16, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) visits.
You asked the Plan to pre-approve PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance program, are the specialized
skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the drug is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Retacrit is indicated for the treatment of anemia of chronic kidney disease. However, correctable causes of anemia should be treated prior to initiating. The enrollee has iron deficiency anemia that should be corrected to see if Retacrit is still indicated. Iron is needed to support the efficacy of Retacrit. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-assured pressure support mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary for the enrollee. This patient has likely obstructive sleep apnea (OSA)and obesity hypoventilation syndrome (OHS), with a recent hospitalization for exacerbation of heart failure with preserved ejection fraction (HFpEF) with acute-on-chronic hypercarbic respiratory failure. The appropriate treatment for OHS is continuous positive airway pressure (CPAP) or BiPAP. This patient does not have a diagnosis of COPD, neuromuscular disease, or thoracic restrictive disease. A BiPAP has not been tried at home. Medicare does not cover a home ventilator for treatment of OHS. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.  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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory allergy panel provided to the enrollee on April
27, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says these tests do not have clinical relevance, are not validated, lack sufficient quality control, and
should not be performed.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there were no clinical records provided documenting a history and physical examination of the enrollee
that would indicate a need for testing as defined by the LCD.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for a respiratory allergy panel provided to the enrollee on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a walking boot (L4361) and a specialist physician office visit (99203) provided on October 29, 2020.
You asked the Plan to waive the cost-sharing for a walking boot and an office visit. You say that you dispute the assessed cost-sharing. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $45 copayment for services obtained from a
specialist and 20% coinsurance for Medicare-covered durable medical equipment benefits.
You have been asked to pay a $45 copayment for an office visit and $60.52, or 20% of the Medicare-allowed
amount of $302.61, for a walking boot. An office visit falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category. A walking boot falls within the "Durable medical equipment
(DME) and related supplies" 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 cost-sharing for a walking
boot (L4361) and a specialist physician office visit (99203) provided on October 29, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission for a laparoscopic hernia repair.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says an observation stay is more prudent in this case.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case.
Our physician reviewer found the record indicates that the enrollee is scheduled for a laparoscopic ventral hernia repair. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission for a laparoscopic hernia repair
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4341 x4), four gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630 x2) provided on September 22, 2021.
You asked the Plan to pay for the scalings and planings, gingival irrigations, and drugs or medicaments. You say that you should have been made aware of the additional costs prior to the services being rendered. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that when you contacted the Plan you did not verify your benefits for periodontal services, and were also advised that your plan is code specific.
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 four
periodontal scalings and root planings (D4341 x4), four gingival irrigations (D4921 x4), and drugs or
medicaments dispensed in the office for home use (D9630 x2) provided on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services coded as 22326 provided on March 26, 2021.  You asked the Plan to pay for the surgery services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support payment for the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 22326 is open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the surgery services. Our reviewer says that the documentation does not support the service as billed. Our reviewer found the operative report does not describe, per the National Correct Coding Initiative Policy Manual, incision of paravertebral muscles and retract to expose fractured vertebra or dislocated segment, and hardware placed above and below the fracture to align the spine. As this procedure was not found in the operative report it cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services coded as 22326 provided on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is medically stable and does not require daily physician oversight for continued therapy needs.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for metabolic encephalopathy and coronavirus pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (procedure code 64494) provided to the enrollee on July 1, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services at issue in this case were not supported by the medical records.
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 64494 is "Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the provider reported CPT 64494 twice with LT and RT modifiers appended. The services should be reported with one unit and modifier 50.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (procedure code 64494) provided to the enrollee on July 1, 2021.