Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple epidural injections provided on the same day.
You asked the Plan to pre-approve multiple epidural injections provided on the same day. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says while these services are approved, they cannot be provided on the same day.
The Plan must follow Medicare rules. Medicare rules say that it is not routinely necessary for multiple blocks to be provided to a patient on the same day as facet joint procedures. We looked at the file and Medicare rules. In this case, there are no medical records provided that support the unique circumstances of the medical necessity for injections on the same day. Based on this information, we decided that Medicare rules for coverage of multiple epidural injections provided on the same day have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple epidural injections provided on the same day.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy provided on April 9, 2021.
You asked the Plan to pay for the electrical stimulation therapy. You say that you are a contracted provider and the claims should be processed at the in-network benefit level. The Plan denied your request. The Plan says procedure code 97112, 97140 and 97150 was paid. The Plan also says that the billed code 97014 denied as it is not valid for Medicare purposes.
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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended).
We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 12, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that this is the first time you have been to this provider this year for a cleaning. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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 one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on February 12, 2020 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 July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Ranibizumab injections provided on April 15, 2021.
You asked the Plan to waive the coinsurance for the Ranibizumab injections. You say that you have been receiving this injection for the last five years and have only had a copayment for the visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 all other in-network drugs covered under Medicare Part B.
You have been asked to pay $312.26 which is 20% of the allowed amount for each of the Ranibizumab injections. The allowed amount is $1,561.30. ($1,561.30 x 20% = $312.26). ($312.26 + $312.26 = $624.52). The Ranibizumab injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Ranibizumab injections provided on April 15, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 28, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had a routine eye exam and are being charged for a specialist office visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for an exam eye to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows your existing macular drusen was discussed in addition to the comprehensive eye exam. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on June 24, 2021.
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that you would like to be reimbursed for the original crown. The Plan denied your request. The Plan says your plan does not cover these procedures.
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 custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on June 24, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on April 1, 2021.
You asked the Plan to pay for the topical application of fluoride varnish. You say that you received a $99.00 reimbursement check, but the Plan still owes you another $84.15. The Plan denied your request. The Plan says this service is not covered. The Plan also says that they contacted the provider's office and were advised that you have already received your refund.
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 topical application of fluoride varnish (D1206) provided on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on September 17, 2020.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the PET scan was billed with an inappropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used.
We looked at the file and Medicare rules. The PET scan in question was billed with diagnosis code C06.9. This is not listed as an appropriate diagnosis code to bill for a PET scan. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not
support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility services (99380) provided on March 29, 2021.
You asked the Plan to pay for the nursing facility services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the claim is always bundled into payment for other services not specified.
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 99380 is Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.
We find that CPT code 99380 is not supported in the medical record. Specifically, CPT code 99380 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99380. Based on this information, we decided that Medicare rules for coverage of the nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility services (99380) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 4, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that if the member is sent home it would put his life in jeopardy. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronavirus pneumonia, deep vein thrombosis, anemia, and gastrointestinal bleeding. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin graft procedure billed for services on March 16, 2021.
You asked the Plan to pay for the billed services. You say that medical documentation supports the code. The Plan denied your request. The Plan says the code is not 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, the CPT Code Manual definition of code 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk. We find that CPT code 15734 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the skin graft procedure billed for services on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular study provided on April 26, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the code was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 99376 was billed with 76856. We find that CPT code 93976 may be eligible for separate payment when billed with this code combination. The claim provided did not show that a suitable modifier was appropriately appended. 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 vascular study provided on April 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 21, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare uses another code for the reporting of these services.
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 A0380 is basic life support mileage (per mile). We find that CPT code A0380 not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. The Medicare Claims Processing Manual shows that code A0380 is not included in the codes that are effective for billing ambulance services on or after January 1, 2021.
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 services provided on January 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits.
You asked the Plan to pre-approve 6 additional home health physical therapy visits. You say that this is medically necessary. The Plan denied your request. The Plan says you can be treated with a home exercise program.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 6 additional home health physical therapy visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the records show that you do not have documented skilled nursing or needs. Your care needs appear to be custodial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel provided on April 6, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no Medicare benefit for screening cardiovascular risk assessment testing for asymptomatic patients.
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 test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening panel provided on April 6, 2021