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

We decided that the Plan does not have to pay for the brachial plexus injection provided on May 26, 2021.

You asked the Plan to pay for the services provided. You say that the correct modifier was used. The Plan denied your request. The Plan says the claim was not billed with a required modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that CPT code 64415 has a bilateral indicator of 1. The billed claim does not include an anatomical modifier. 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 brachial plexus injection provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit and the laboratory services rendered by the out-of-network (OON) provider on June 15, 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 hospital outpatient clinic visit and the laboratory services rendered by the out-of-network (OON) provider on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on April 19, 2021, to May
17, 2021, by an OON provider.
You asked the Plan to pay for the chiropractic services. You say that you had a sudden back injury and chose to
get medical help from the nearest available provider. 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 services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the chiropractic services provided on April 19, 2021, to May 17,
2021, by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over
and above those usually included in an office visit or other non-facility service(s) coded 99072 provided on
November 5, 2020.

You asked the Plan to pay for the additional supplies, materials, and clinical staff time over and above those
usually included in an office visit or other non-facility service(s). You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately
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 99072 is additional supplies, materials, and clinical staff
time over and above those usually included in an office visit or other non-facility service(s), when performed
during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status
indicator of "B." A status code of B means that this code is always bundled into payment for other services not
specified and no separate payment can be made. Based on this information, we decided that Medicare rules for
coverage of the additional supplies, materials, and clinical staff time over and above those usually included in
an office visit or other non-facility service(s) have not been met. Therefore, we decided that the Plan does not
have to pay for the additional supplies, materials, and clinical staff time over and above those usually included
in an office visit or other non-facility service(s) coded 99072 provided on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality injection (J3590), 120 mg/ml.

You asked the Plan to pre-approve Emgality. You say that the enrollee has tried and failed other medications. You also say that Emgality is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 pre-approve Emgality injection (J3590), 120 mg/ml.

Benefits for Emgality 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on November 19, 2020.

You asked the Plan to pay for code 99100. 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. Code 99100 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on November 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current facility. Therefore, LTACH services will be considered not medically
necessary as transfer would not be advantageous. Transfer to a lower level of care may be considered when
treatment has completed.
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on June 3, 2021.

You asked the Plan to pay for the dental service. You say that you do not understand why the plan does not downgrade the coverage to a regular exam. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as a covered 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, the comprehensive periodontal evaluation not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear (85060) provided on May 11, 2021.

You asked the Plan to pay for the blood smear. You say that you would like reconsideration because this claim was billed with the appropriate place of service code. The Plan denied your request. The Plan says payment for this code may not be made for hospital outpatients.

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 85060 is not supported in the record. Specifically, CPT code 85060 has a Professional/Technical Flag of 8. This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. No payment is recognized for CPT code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare rules for coverage of the blood smear have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear (85060) provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 28,
2021.

You asked the Plan to pay for the CT scan. 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 allowed modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that CPT code 70450 was billed with 70496. The CPT code 70450 is separately payable when billed
with this code pair. However, the code at issue was not billed with an appropriate modifier. Based on this
information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we
decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Peroral Endoscopic Myotomy surgery provided on June 30, 2021.

You asked the Plan to pay for the esophagus procedure (43499). You say that you needed this surgery as your food was not able to go down so easy. The Plan denied your request. The Plan says the Plan does not pay for services that are experimental or investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Pre-authorization for this procedure was denied before the date of service. The Plan considers this procedure as experimental. Based on this information, we decided that Medicare rules for coverage of the esophagus procedure (43499) have not been met. Therefore, we decided that the Plan does not have to pay for the Peroral Endoscopic Myotomy surgery provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical fluoride varnish; therapeutic application for moderate to high caries risk patients (D1206) provided July 1, 2021.

You asked the Plan to pay for the fluoride varnish. You say that you disapprove of the denial. The Plan denied your request. The Plan says this service is not covered under your 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 the topical fluoride varnish; therapeutic application for moderate to high caries risk patients (D1206) provided July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that epidural injections for pain management are only covered under certain medical indications. 

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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. He is status post a stroke and is on Eliquis. He also has an abnormal complete blood count (CBC). His magnetic resonance imaging (MRI) shows an L2 compression fracture, congenital spinal stenosis at L3-L4 and L4-L5, and multi-level degenerative disc disease. He is taking Norco for pain. Her has had chiropractic therapy. The enrollee is on an anticoagulant and has an abnormal CBC. These issues need to be addressed prior to any injection. Therefore, the request, at this time, is deemed not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you no longer require daily skilled services that can only be provided in a SNF.

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 continued services. Our physician reviewer found that you were at an independent assist level for sitting up, lying down, standing up, transfers, and walking. You do not have any documented skilled nursing or skilled therapy needs. You are mobilizing independently. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided April 2, 2021, and the periodontal scaling and root planing - four or more teeth per quadrant (D4341), periodontal scaling and root planing - one to three teeth per quadrant (D4342), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), gingival irrigation - per quadrant (D4921), and drugs or medicaments dispensed in the office for home use (D9630) provided April 8, 2021.

You asked the Plan to pay for the adjunctive pre-diagnostic test, periodontal scaling and root planing, localized delivery of antimicrobial agents, gingival irrigation and drugs for home use. You say that you thought the Plan would cover the services. The Plan denied your request. The Plan says these services are not covered under your 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 were not among those covered under this benefit at the time of service. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided April 2, 2021, and the periodontal scaling and root planing - four or more teeth per quadrant (D4341), periodontal scaling and root planing - one to three teeth per quadrant (D4342), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), gingival irrigation - per quadrant (D4921), and drugs or medicaments dispensed in the office for home use (D9630) provided April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided
on December 3, 2020.
You asked the Plan to pay for code 99100. 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. We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on June 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that you are an independent laboratory and do not receive patient information until after services are rendered. You say the enrollee was seen by an in-network provider with no control over the laboratory they used. The Plan denied your request. The Plan says the claim originally denied because it was not reported with an appropriate diagnosis, but not 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 services at issue were urgent or emergent. The record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 1, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery provided on June 14, 2021.

You asked the Plan to waive the copayment for the cataract surgery. You say that you paid out-of-pocket for services and you say you believe you should be reimbursed. 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 $265 copayment for at an in-network ambulatory surgical center.

You have been asked to pay a $265 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cataract surgery provided on June 14, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 does 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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.