Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair (PWC) (K0814).  You asked the Plan to pre-approve a PWC. You say that the item is medically necessary. The Plan denied your request. The Plan says it is not clear if your injury is reversible.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 PWC. Our reviewer says that you do not need this item. Our physician reviewer found the documentation indicates that a power wheelchair would not be safe as you are currently unable to safely transfer into this device and you have not had complete treatment or therapy for your shoulder injury which may be a reversible condition.  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 PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC) (K0814).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (00860) provided on August 17, 2021.  You asked the Plan to pay for code 00860. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  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 00860 is Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified.  We find that CPT code is not supported in the medical record. Specifically, an appropriate surgical procedure code that crosswalks with the billed anesthesia code was not reported. Based on this information, we decided that Medicare rules for coverage of code 00860 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00860) provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrical bone growth stimulator (E0747) provided on April 23, 2021.
You asked the Plan to pay for an electrical bone growth stimulator. You say that the preauthorization for the item at issue was not denied but only postponed. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for failed fusion where a minimum of 9 months has elapsed since the last surgery. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electrical bone growth stimulator have not been met. Specifically, the record shows that when the item at issue was purchased 9 months had not yet elapsed since the last surgery.
Therefore, we decided that the Plan does not have to pay for an electrical bone growth stimulator (E0747)
provided on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 2, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services rendered by the out-of-network (OON) provider on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services provided on August 16, 2021.
You asked the Plan to pay for the services provided. You say that the procedures were distinct and separate. The Plan denied your request. The Plan says the services were not billed as required by coding regulations.
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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters.
The file shows that 4 units of CPT code 95870 were billed. The Plan paid 2 units of service. We find that additional units of CPT code 95870 are not supported in the medical record. Specifically, the records do not identify the muscles or specific extremities that were tested to support the reported services. 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 needle electromyography services provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), periodontal scaling and root planing (D4341), localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), and drugs (D9630), provided on September 14, 2021.
You asked the Plan to pay for the routine dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says these are not covered services.
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 adjunctive pre-diagnostic test (D0431), periodontal scaling and root planing (D4341), localized delivery of
antimicrobial agents (D4381), gingival irrigation (D4921), and drugs (D9630), provided on September 14, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the spinal revision surgery. We decided that the Plan does not have to waive the copayment for the specialist office visit.
You asked the Plan to waive the copayment for the specialist office visit and the spinal revision surgery. You say that you are appealing these claims. The Plan says that you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to waive the copayment for the spinal revision surgery.
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 does not say in clear and accurate terms when you should expect to pay a $0 copayment to a $350 copayment for the spinal revision surgery. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay the $350 copayment for the spinal revision surgery. The Plan contract does not clearly say when enrollees would expect to pay a $0 copayment, up to a $350 copayment for the spinal revision surgery. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the spinal revision surgery provided by in-network providers on October 7, 2021. We also decided that the Plan does not have to waive the copayment for the specialist office visit.
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 $40 copayment for the specialist office visit. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit on August 24, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, 87641, and 87798 provided on October 26, 2020.
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 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. We find that CPT codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, 87641, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a office, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an skilled Nursing Facility
setting, place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, 87641, and 87798 provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided July 19, 2021.
You asked the Plan to pay for the pain management services. You say that this code is not limited to just injecting corticosteroid preparations nor is it limited to the epidural space. The procedure you are billing for is
subarachnoid injection of opioid medications. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the provider has not submitted any clinical records to support the medical necessity of the service. The Plan made multiple requests to obtain the additional records from the provider without success. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pain management services have not been met. Therefore, we decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the abdomen (74018) provided on September 10, 2021.
You asked the Plan to pay for an X-ray of the abdomen. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the claim line at issue is a duplicate.
The Plan must follow Medicare rules. Medicare 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. Based on this information, we decided that Medicare rules for coverage of an X-ray of the abdomen have not been met. Specifically, the Plan has documented that the claim line at issue is a duplicate of a claim line that has been processed and paid. Therefore, we decided that the Plan does not have to pay for an X-ray of the abdomen (74018) provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 3, 2020.
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 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. We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a skilled nursing setting, place of service 31.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on July 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied your request. The Plan says this was not authorized.
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 office visit (99204) provided on July 29, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fundus photography (92250), provided on October 1, 2021.
You asked the Plan to pay for the fundus photography. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the vision related services listed in the Plan's benefit chart. We looked at the file and the Plan's rules. this service is not listed in the Plan's benefits. Based on this information, we decided that the Plan's rules for coverage of the fundus photography have not been met. Therefore, we decided that the Plan does not have to pay for the fundus photography (92250), provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), and excision of a benign lesion (D7410) provided on September 7, 2021.
You asked the Plan to pay for the dental services. You say that you are on a fixed income. You say that the dentist advised they would not put a crown on the tooth because there was something going on under the tooth. You say that you waited a year as it was not bothering you. You also say that this should be covered because it should have been pulled a year ago. The Plan denied your request. The Plan says the services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the excision of a benign lesion is not among those covered under this benefit. Additionally, the record shows that the Plan paid for the surgical extraction under your dental coverage.
Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210), and excision of a benign lesion (D7410) provided on September 7, 2021, under your medical coverage.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 22, 2020.
You asked the Plan to pay for the services. You say that these codes are payable to the assistant surgeon. The Plan denied your request. The Plan says services were not provided on April 22, 2020.
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 19318, 14301, 14302 as billed for April 22, 2020 are not supported in the medical record. Specifically, the services were billed with a date of service range starting on April 22, 2020. The records do not show any evidence that there were any services provided on this date. 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 surgical services provided to the enrollee on April 22, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that there is no expectation that further daily therapy will result in measurable gains in a reasonable and predictable period of time.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) infrared light therapy (97026) manual therapy techniques (97140) provided May 28, 2021.
You asked the Plan to pay for the acupuncture services. You say that the enrollee was seen for acupuncture treatment to alleviate neck pain. The Plan denied your request. The Plan says these services are not covered. A licensed acupuncturist is not the appropriate provider type to provide a physical therapy service.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan contract specifically says that acupuncture is covered for the treatment of low back pain. The records show that the acupuncture was for the treatment of neck pain. Infrared therapy is not covered by Medicare. A licensed acupuncturist is not the appropriate provider type to provide a physical therapy service. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) infrared light therapy (97026) manual therapy techniques (97140) provided May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 5, 2021.
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 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. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. 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 March 5, 2021.