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

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate when used as bone graft material. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 7, 2021 by a non-participating provider.
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 services were rendered by a non-participating provider without prior authorization.
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 referring provider 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 the laboratory services provided on June 7, 2021 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 71045 provided on June 16, 2021. 
 
You asked the Plan to pay for the x-ray. 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 71045 
for the x-ray has a bundled relationship with code 74022 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 x-ray coded 71045 provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
July 24, 2020. 
 
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.

We find that CPT code 99223 is not supported in the medical record. Specifically, no clinical documentation 
(including medical records) was provided to support the services billed. Based on this information, we decided 
that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the initial hospital care services coded 99223 provided on July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the flow cytometry services coded 88185 provided on January 5, 2021.
You asked the Plan to pay for the flow cytometry services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88185 is flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker).
We find that CPT code 88185 is not supported in the medical record. Specifically, no medical documentation (including medical records) was provided to support the code billed. Based on this information, we decided that Medicare rules for coverage of the flow cytometry services have not been met. Therefore, we decided that the Plan does not have to pay for the flow cytometry services coded 88185 provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 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 laboratory testing 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 laboratory services provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 26, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a periodic oral evaluation (D0120), core buildup (D2950), prophylaxis (D1110) a crown (D2740) and a periapical radiographic image (D0220) provided on March 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to reimburse you an additional amount for a periodic oral evaluation, core buildup, prophylaxis, a crown and a periapical radiographic image. You say that you do not agree with the denial of your claim. The Plan denied your request. The Plan says you received services from an OON provider. If you see an OON provider, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. The Plan also says you are responsible for the difference between the INFS and providers' charged fees.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and Medicare rules. The records show that you received services from an OON provider. The EOC confirms that you pay a 50% coinsurance for a periodic oral evaluation, prophylaxis, a crown and a periapical image. The contract confirms that a core buildup is not covered under your benefit Plan. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, core buildup, prophylaxis, a crown and a periapical radiographic image have not been met. Therefore, we decided that the Plan does not have to reimburse you an additional amount for a periodic oral evaluation (D0120), core buildup (D2950), prophylaxis (D1110) a crown (D2740) and a periapical radiographic image (D0220) provided on March 25, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the 20% coinsurance charged for a Zoll Life Vest.
You asked the Plan to waive this coinsurance. You say that you only used this equipment for a short time and feel the coinsurance is excessive. The Plan denied your request. The Plan says this coinsurance was charged based on the claim submitted by your provider and the Plan contract agreement.
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 20% coinsurance for durable medical equipment. 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 20% coinsurance charged for a Zoll Life Vest provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 21, 2020. 
 
You asked the Plan to pay for the drug testing. 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. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic met hods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the services billed are a 
duplicate. The documentation shows that this service was previously processed and paid under another claim 
number for this date of service. Based on this information, we decided that Medicare rules for coverage of the 
drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
coded G0483 provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary for palliative therapy for bladder cancer. The Plan denied your request. The Plan says there is no documentation to support the medical necessity of this request.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there must be justification for the use of intensity-modulated radiation therapy (IMRT). It can be necessary when the need for is sufficiently supported. The medical records do not offer an explanation as to why, or offer a quantifiable rationale, for why IMRT is needed in this patient. No specific information about a 3D conformal plan being unacceptable was provided. Without justification for the need of radiotherapy, or the need for IMRT (over standard 3D conformal radiotherapy), this cannot be considered 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of arterial inflow and venous outflow coded 
93976 provided on June 12, 2021. 

You asked the Plan to pay for the duplex scan of arterial inflow and venous outflow. 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 93976 
for the duplex scan of arterial inflow and venous outflow has a bundled relationship with code 76856 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 
duplex scan of arterial inflow and venous outflow coded 93976 provided on June 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need physical therapy to get stronger. The Plan denied your request. The Plan says you have no skilled nursing needs, and not acute skilled therapy needs.
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 services. Our physician reviewer found that You are at a standby assist level for transfers, bed mobility, and functional mobility. You are at a contact guard assist level for ambulation using a four-wheeled walker. You do not require the services of a skilled professional nurse to provide medically necessary treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. Your functional level does not require services of a qualified therapist to provide medically necessary treatment in a SNF. You do not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 5, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 

We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for WATS3D testing (88361) provided on May 5, 2021.
You asked the Plan to pay for WATS3D testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not indicated for the enrollee's diagnosis.
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 WATS3D testing. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain clinical documentation that the enrollee in this case has known or suspected Barrett's esophagus.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of WATS3D testing have not been met. Therefore, we decided that the Plan does not have to pay for WATS3D testing (88361) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for various services provided to the enrollee on March 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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99072: 
 
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 
 
HCPCS A4550:

Surgical trays 
 
HCPCS A4556: 
 
Electrodes, (e.g., apnea monitor), per pair 
 
HCPCS A4557: 
 
Lead wires, (e.g., apnea monitor), per pair 
 
HCPCS A4649: 
 
Surgical supply; miscellaneous 
 
HCPCS A9999: 
 
Miscellaneous durable medical equipment (DME) supply or accessory, not otherwise specified 
 
HCPCS S1015: 
 
IV tubing extension set 
 
HCPCS S8301: 
 
Infection control supplies, not otherwise specified 
 
We find that the various denied are not supported in the medical record. 

Specifically, for S1015 and S8301, these codes have a status indicator of I according to the Medicare 
Physician's Fee Schedule. This indicates that the codes are not valid for Medicare purposes.  
 
Specifically, for A4550 and 99072, these codes have a status indicator of "B" which means that payment for 
these codes is always bundled into payment for other services not specified, and no separate payment can be 
made. 
 
Specifically for A4556, A4557, and A4649, these codes have a status indicator of "P" which means that 
payment for these codes is always bundled into payment for other services not specified, and no separate 
payment can be made. 
 
Specifically for A9999, this code has a status indicator of "X" which means that payment for these codes is 
always bundled into payment for other services not specified, and no separate payment can be made. 
 
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 various services provided to the enrollee on March 
1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) rendered on August 22, 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 magnetic resonance angiography (MRA) rendered on August 22, 2020.