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

 We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 83970, 84100, 87340) provided on June 8, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare consolidates into dialysis services the laboratory testing related to the treatment of ESRD.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 83970, 84100, 87340) provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an incisional biopsy (D7286), and sedation (D9222 and D9223) provided on August 13, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for an incisional biopsy and sedation. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says services were not provided by an in-network physician.  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 an incisional biopsy (D7286), and sedation (D9222 and D9223) provided on August 13, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on September 2, 2021.  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 there is no valid physician order.  The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any durable medical equipment (DME) item to a beneficiary.  We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor supplies rendered on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the autograft for spine surgery (20938) and allograft (20930) provided on July 22, 2021.  You asked the Plan to pay for the autograft for spine surgery (20938) and allograft (20930). You say that the documentation and operative report support the denied charges. You say that the codes should be processed for payment. The Plan denied your request. The Plan says procedure code 20938 is not supported by the medical records The Plan also says procedure code 20930 has a status indicator of B and bundled services are not separately reimbursed.  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 20938 is autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 20930 is a allograft, morselized, or placement of osteopromotive material, for spine surgery only (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 autograft for spine surgery (20938). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that an autograft for spine surgery was performed on July 22, 2021, therefore this procedure cannot be verified.  We also find that CPT code 20930 is not supported in the medical record. Specifically, CPT code 20930 has a status indicator of B. This means that CPT code 20930 is considered bundled and not separately payable.  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 autograft for spine surgery (20938) and allograft (20930) have not been met. Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery (20938) and allograft (20930) provided on July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on August 25, 2021.  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 are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on August 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuromonitoring services (95938, 95861) provided on June 2, 2021.  You asked the Plan to pay for the neuromonitoring services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not covered as billed.  The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.  We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services (95938, 95861) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the tertiary level of care otolaryngology office visit.  You asked the Plan to pre-approve the tertiary level of care. You say that you would like reconsideration because the requested office visit is medically necessary. The Plan denied your request. The Plan says the notes do not show that you require a higher level of care or that a redirection would cause a delay in care.  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 tertiary level of care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no documentation to indicate you require more advanced otolaryngologic services for the treatment of sensorineural hearing loss; no modifications to your existing hearing aids were prescribed. Moreover, available clinical notes did not document any concerning findings on magnetic resonance imaging or upcoming need for imaging or other studies that might warrant tertiary care expertise.  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 tertiary level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve the tertiary level of care otolaryngology office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on September 3, 2020.  You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 23472 is an inpatient only procedure with a status indicator of C.  The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.   The service at issue in this appeal was billed with CPT code 23472. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tumor resection (22905) and abdominal lymphadenectomy (38747) provided on July 30, 2021.   You asked the Plan to pay for the tumor resection (22905) and abdominal lymphadenectomy (38747). You say that per the coder, the records support the charges and should have been paid. The Plan denied your request. The Plan says CPT code 22905 is not supported. The Plan also says that CPT code 38747 is included in CPT code 44160 and cannot be separately reimbursed.  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 22905 is radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater. The CPT Code Manual definition of code 38747 is abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (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 tumor resection (22905) and abdominal lymphadenectomy (38747). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not include documentation to support the size of tumor 5cm or greater and therefore, CPT code 22905 cannot be confirmed. CPT code 38747 would be inclusive to the hemicolectomy performed, as these procedures were performed at the same anatomical site during the same session. Therefore, these procedures should not be reported separately.  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 rumor resection (22905) and abdominal lymphadenectomy (38747) have not been met. Therefore, we decided that the Plan does not have to pay for the tumor resection (22905) and abdominal lymphadenectomy (38747) provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an echocardiography, transthoracic, real-time with image documentation (2D).  You asked the Plan to pre-approve an echocardiography, transthoracic, real-time with image documentation (2D). The Plan denied your request. The Plan says the enrollee's doctor must send in supporting clinical documentation for medical necessity review and determination. The Plan says that the Plan did not receive any supporting clinical notes from the enrollee's doctor's office and therefore this request was denied. Had the doctor's office sent us these required notes, your request for an echocardiogram could have been considered for approval.  The Plan must follow Medicare rules. Medicare rules say for Medicare to consider coverage and payment for any item or service, 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. The file shows that you did not submit sufficient medical documents to justify coverage of the requested service. Therefore, we decided that the Plan does not have to pre-approve an echocardiography, transthoracic, real-time with image documentation (2D) (93306).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 7, 2021.  You asked the Plan to pay for the limited exam. You say that this was a routine exam and should have been covered by your dental benefit. The Plan denied your request. The Plan says this service is not covered by 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.  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. A limited exam is provided to evaluate a problem or specific area of the mouth and is not the same as a routine/periodic oral exam. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete (76770) provided August 23, 2021.  You asked the Plan to waive the copayment for the retroperitoneal ultrasound. You say that you would like the Plan to cover this service. The Plan denied your request. The Plan says the copayment was applied 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 $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility.  You have been asked to pay a $99.61 copayment for the retroperitoneal ultrasound. The retroperitoneal ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay less than or equal to 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 ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete (76770) provided August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a home visit (99347, G8417, G8427, G8950) provided on July 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a home visit. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and based on the documentation submitted, we have determined that the services rendered to the member are not urgent or emergent, nor were they approved in advance by a 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 a home visit (99347, G8417, G8427, G8950) provided on July 16, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Soliris (J1300).
You asked the Plan to pre-approve Soliris. You say that Soliris is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Soliris. Our reviewer says that Soliris is medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of paroxysmal nocturnal hemoglobinuria. The Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The elements of the coverage criteria are 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 Soliris have been met. Therefore, we decided that the Plan has to pre-approve Soliris (J1300).
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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar spinal fusion for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation states that the enrollee is a current smoker, and there is no indication of a plan to stop smoking prior to surgery.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a smoker, which is a contraindication to the requested surgery. There is no documentation of smoking cessation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion for the enrollee.
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 for the requested service 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 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 device is experimental. More research on the device is needed to establish 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower
denture (D5214).
You asked the Plan to pre-approve dentures. You say that you had your teeth extracted. You say that you
received immediate dentures while your gums healed. You say that the immediate dentures no longer fit and
you need permanent dentures. You also say that these were approved previously. The Plan denied your request.
The Plan says dentures are covered once per arch every 5 years. The Plan also says that the frequency limit has
been reached.
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. Based on this information, we decided that the Plan's rules for
coverage of dentures have not been met. Specifically, the file shows that the frequency limits have been
reached. The record shows that the Plan paid for an immediate upper denture (D5130) and immediate partial
denture (D5222) that you received on May 5, 2021. Therefore, we decided that the Plan does not have to preapprove
a complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a colonoscopy provided on May 21, 2021.  You asked the Plan to pay for the colonoscopy. The Plan denied your request. The Plan says the health Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.  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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a colonoscopy provided on May 21, 2021.