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

 We decided that the Plan does not have to pay for an ultrasound (76536) provided October 24, 2021.  You asked the Plan to pay for the ultrasound. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim was billed with an invalid place of service.  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 76536 is not supported in the medical record. Specifically, the claim form shows an outpatient place of service, however the records show that the enrollee was an inpatient at the time this service was provided. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76536) provided October 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a prefabricated shoulder "airplane design" abduction orthosis (L3960) provided May 14, 2021.  You asked the Plan to pay for the orthosis. You say that please review the attached medical records. The Plan denied your request. The Plan says there is evidence of misrepresented services.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.   Our physician reviewer found the clinical documentation in the case file does not support that a shoulder orthosis was medically reasonable and necessary for the enrollee in this case. There is no medical documentation of a right shoulder complaint or medical condition requiring a shoulder orthosis.  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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a prefabricated shoulder "airplane design" abduction orthosis (L3960) provided May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for self-administered drugs provided from May 17, 2021, to May 19, 2021.  You asked the Plan to pay for self-administered drugs. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because self-administered drugs are not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided from May 17, 2021, to May 19, 2021.   Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to your CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal cord injection (62320) provided on August 23, 2021.

You asked the Plan to pay for the spinal cord injection (62320). You say that the procedure billed is for subarachnoid injection therefore the policy of interlaminar epidural injections is not applicable. You say that subarachnoid opioids are very effective for decreasing pain and the service should be paid. The Plan denied your request. The Plan says the 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Medicare rules also 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 spinal cord injection (62320) have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the spinal cord injection (62320) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient facility services provided on February 17, 2020, through March 29, 2020 and billed with DRG 166.  You asked the Plan to pay for the inpatient facility services. You say that you would like reconsideration because the documentation supports the DRG billed. The Plan denied your request. The Plan says the documentation does not support the DRG billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 166. 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 inpatient facility services. Our reviewer says that the documentation submitted does not support DRG 166. Our physician reviewer found the submitted selections from the medical record do not include documentation substantiating the excisional debridement procedures, skin destruction procedures or infusion device insertion procedure reported in the Hospital claim. The review has determined that the documentation did not include documentation substantiating the excisional debridement procedures, skin destruction procedures or infusion device insertion procedure.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient facility services provided on February 17, 2020, through March 29, 2020 and billed with DRG 166.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tooth extraction (D7210), a bone graft (D3428), and an intraoral imaging (D0220) provided by participating providers on August 10, 2021, and August 26, 2021.  You asked the Plan to pay for a tooth extraction, a bone graft, and an intraoral imaging. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the dental services that were provided are not covered benefits.  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 a tooth extraction (D7210), a bone graft (D3428), and an intraoral imaging (D0220) provided by participating providers on August 10, 2021, and August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient hospital care provided from  September 27, 2021, through September 28, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.     The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that based on the provided documentation, although the surgery appears to be supported, the inpatient admission does not. There was no indication at the time of admission that the enrollee would require hospital services that would likely cross 2 midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care provided from September 27, 2021, through September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services (70543, 70553) provided on August 3, 2021.  You asked the Plan to pay for the MRI services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says screening tests are not covered by Medicare or by the Plan.  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, the MRI services, was requested solely for screening purposes. No evidence was provided to support the medical necessity of the requested services beyond screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services (70543, 70553) provided on August 3, 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 by an out-of-network provider on October 21, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that this was an out-of-network visit, and you reached your stop loss. 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 $50 copayment for provider and professional services at an out-of-network specialist's office.    You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 copayment for the specialist office visit provided by an out-of-network provider on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for full hereditary cancer screening panel testing provided on August 16, 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 documentation to support the need for each biomarker performed in this panel and these biomarkers are not covered as screening tests.  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 solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for full hereditary cancer screening panel testing provided on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the allograft (20930), autograft for spine surgery (20936) and neuroplasty (64721) provided on August 11, 2021.  You asked the Plan to pay for the allograft (20930), autograft for spine surgery (20936) and neuroplasty (64721). The Plan denied your request. The Plan says CPT codes 20930 and 20936 are considered bundled and not separately payable. The Plan also says that assistant surgeon services are not payable for CPT code 64721.   The Plan follows Medicare rules. Medicare rules say that providers must report services correctly and must report services with the appropriate CPT code. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered.   In this case, we find that CPT codes 20930 and 20936 are not supported in the medical records. Specifically, CPT codes 20930 and 20936 have a status indicator of B. This means that CPT codes 20930 and 20936 are considered bundled and not separately payable.  In addition, assistant surgery services were billed for Current Procedural Terminology (CPT) code 64721. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the neuroplasty (64721) have not been met. Therefore, we decided that the Plan does not have to pay for the allograft (20930), autograft for spine surgery (20936) and neuroplasty (64721) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2021.  You asked the Plan to pay for the laboratory services. 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an outpatient hospital setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on September 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that you would like these services reprocessed based on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 domiciliary or rest home visit (99336) provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the somatosensory testing (95927) provided on March 28, 2021.  You asked the Plan to pay for the somatosensory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head.  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 somatosensory testing. Our reviewer says that CPT code 95927 does not meet criteria for billing or reimbursement consideration. Our reviewer found the technical report does not document Short latency somatosensory evoked potential study, recording from central nervous system trunk or head.  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 somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for the somatosensory testing (95927) provided on March 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on August 23, 2021.  You asked the Plan to reimburse you for the hearing aids. You say that you believed that the Plan's hearing network provider and the provider you received the hearing aids from had an association and that you were following the Plan guidelines by receiving your devices from there. You say that this provider should have known that the devices needed to be purchased from the Plan's hearing network provider. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are not purchased from the Plan's hearing network provider, and the hearing benefit is not covered if the services are not registered in advance.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been me Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 and D4342) provided by a participating provider on August 26, 2021.  You asked the Plan to pay for periodontal scaling and root planing. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered services are not covered benefits.  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 periodontal scaling and root planing (D4341 and D4342) provided by a participating provider on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for Fundus photography provided on  October 28, 2021.  You asked the Plan to waive the copayment for an eye exam. You say that this service was for a diabetic retinopathy eye scan and since you have diabetes, this should be covered in full. The Plan denied your request. The Plan says the correct copayment was applied to the claim for a medical eye exam.  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 $50 copayment for Vision Care, Medical Eye Exam.   You have been asked to pay the allowable amount of $26.53, which is less than the $50 copayment for the Fundus photography. The Fundus photography falls within the Vision Care, Medical Eye Exam 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 copayment for the Fundus photography provided on  October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Rhythm electrocardiogram (93042) provided on June 3, 2021.  You asked the Plan to pay for code 93042. 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 is a column II code to column I code 99291. 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 the Rhythm electrocardiogram (93042) provided on June 3, 2021.