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

 We decided that the Plan does not have to pre-approve an outside scooter (99998).  You asked the Plan to pre-approve an outside scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an outside scooter (99998).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (CPT code 77003-59) provided on August 17, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. As the CPT code 77003 was billed without an appropriate primary code and not performed by the same practitioner on the same date of service; we find that Medicare rule for payment for CPT code 77003 has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (CPT code 77003-59) provided on August 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on October 14, 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 76700 (abdominal ultrasound) and 93976 (vascular study). Code 76700 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76700 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 abdominal ultrasound rendered on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia (CPT code 99100) provided to the enrollee on May 13, 2021.  You asked the Plan to pay for the anesthesia. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered 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. Our records indicate that CPT code 99100, which has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare. Therefore, we decided that the Plan does not have to pay for the anesthesia (CPT code 99100) provided to the enrollee on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on September 28, 2021.  

You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says complete treatment records for review to support the CGM and supplies ordered were not received.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.  

The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on November 18, 2021.  You asked the Plan to pay for the core buildup. You say that you were in pain and this service should be covered. You also say that you are on a fixed income, and you would like the dentist to be paid so you can be reimbursed. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.  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 core buildup, including any pins when required (D2950) provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an automatic external defibrillator with integrated electrocardiogram analysis (K0606), provided on August 24, 2021, to September 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an automatic external defibrillator with integrated electrocardiogram analysis. You say that the item is medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services through an out-of-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 an automatic external defibrillator with integrated electrocardiogram analysis (K0606), provided on August 24, 2021, to September 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot inserts (L3020).  You asked the Plan to pre-approve foot orthotics. You say that you need this item. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 3, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that in 2021 you went to your dentist and he retired so you had to find a new dentist. You say that you moved about 20 miles away from your old dentist and had to get a new dentist. You also say that you do not get an oral evaluation every year, but under the circumstances feel that the Plan should cover the 2 evaluations. The Plan denied your request. The Plan says the benefit maximum has been met for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.     Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation (D0150) is limited to once every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on May 24, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81301, 81311, 81162, 81292, 81295, 81298, 81317, 81194, and 81309) provided to the enrollee on June 17, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered 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.  The provider billed testing of each gene on a separate line. Medicare coding guidelines requires the ten gene panel be reported with one code, CPT 81445, therefore, this denial is upheld. 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 (CPT code(s): 81206, 81301, 81311, 81162, 81292, 81295, 81298, 81317, 81194, and 81309) provided to the enrollee on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Foundation One Heme testing (81455) provided on July 27, 2021.

You asked the Plan to pay for the Foundation One Heme testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for coverage of the Foundation One Heme testing have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine why this testing was ordered, how the results will affect the member's course of treatment or if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the Foundation One Heme testing (81455) provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 27, 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 an appropriate use of the modifier cannot be validated without a review of 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on June 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 10, 2022, forward.

You asked the Plan to pre-approve inpatient psychiatric care from February 10, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric care from February 10, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment. Our physician reviewer found the enrollee did not require inpatient mental health treatment as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from February 10, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 10, 2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch (64640) for the enrollee.  

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is not enough medical evidence for this procedure.  

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. This procedure is considered experimental/investigational. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch (64640) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed (CPT code 27540-59 RT) provided on April 1, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the 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.  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 service. Our reviewer found CPT code 27540 - open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed billed to the health plan for services provided on April 1, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that an open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed was performed on April 1, 2021; therefore, this procedure 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 service have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed (CPT code 27540-59 RT) provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided July 14, 2021, and October 14, 2021.  You asked the Plan to pay for the dental cleanings. You say that you have advanced periodontitis and require additional cleanings. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental cleanings when the services are medically necessary and reasonable.      We looked at the file and Medicare rules. The Plan provided documentation showing that dental cleanings were previously covered on January 6, 2021, and April 8, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the dental cleanings has been exceeded. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided July 14, 2021, and October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on May 6, 2021.  You asked the Plan to pay for the CGM supplies. You say that the item should be covered. The Plan denied your request. The Plan says until the member has paid the deductible amount, they must pay the full cost for most of their medical covered services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible which applies to durable medical equipment (DME) and related supplies.    The item or service you asked the Plan to pay for falls within the benefit category durable medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to durable medical equipment (DME) and related supplies.  This cost sharing is a contractual obligation that had not been met at the time the CGM supplies was received on May 6, 2021. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on May 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transportation services provided on August 27, 2021.  You asked the Plan to pay for the services provided. You say that the documentation justifies medical necessity. The Plan denied your request. The Plan says the claim was processed correctly.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 services provided. Our physician reviewer found that the enrollee was transported to the hospital via ambulance after reporting 2 hours of chest pain following recent discharge home from hospital for pneumonia. Vitals were normal. He was alert and oriented with normal respiratory effort and clear lungs. Pain was rated as 5/10. ECG showed normal sinus rhythm without abnormality.  He did not receive any treatments during transport. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that he needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. Therefore, the documentation does not support that the ambulance transport was medically reasonable and 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on August 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical/occupational therapy services provided from March 1, 2021, to March 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for physical/occupational therapy services. You say that authorization is not required for physical therapy, per Medicare guidelines. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the Plan, and another non-network provider with the member's the Plan referred the member for services. The Plan also says that there was no 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 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 physical/occupational therapy services provided from March 1, 2021, to March 18, 2021, by an out-of-network (OON) provider.