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

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) provided on October 2, 2021.

You asked the Plan to pay for a CT scan of the head or brain. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request.

The Plan says rules for payment have not been met because the service at issue is bundled to another service billed on the same day by a physician of the same specialty in the same billing group.

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 a computed tomography (CT) scan of the head or brain (70450) provided on October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided on October 29, 2021.

You asked the Plan to pay for wound debridement. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 wound debridement provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specimen handling services rendered on August 3, 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 procedure code 99000 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Billed procedure code 99000 (specimen handling) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the specimen handling services rendered on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Fundus photography provided on October 19, 2021.

You asked the Plan to pay for Fundus photography. The Plan denied your request. The Plan says retinal photography is not covered by most vision plans and therefore it will be an out-of-pocket expense.

The Plan must follow Medicare rules. Medicare rules say Fundus Photography is not covered for routine screening.

We looked at the file and Medicare rules. Medicare says that Fundus Photography is not covered for routine screening. Therefore, we decided that the Plan does not have to pay for Fundus photography provided on October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE.)

You asked the Plan to pre-approve the TTE. You say that the TTE is needed to keep track of what's going on with your heart. You say that there was a change in your heart and your stenosis went from mild to moderate. The Plan denied your request. The Plan says the enrollee has no symptoms of valve disease, and the existing valve disease is documented as medical. The Plan says that the records do not support the medical necessity of a TTE being done in less than one year from the last.

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 the TTE. Our reviewer says that a transthoracic echocardiogram is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of any apparent significant change in the enrollee's clinical condition. Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or new signs, symptoms or physical findings. There is no supportive evidence for the medical necessity of repeat TTE in this this enrollee's clinical management.

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 TTE have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE.)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided September 7, 
2021 to September 10, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that your claim was denied because medical 
records requested from the provider were not received. You are an invisible provider and do not have access to 
records. Please review and reconsider for payment. The Plan denied your request. The Plan says 
missing/incomplete/invalid prior insurance carrier explanation of benefits (EOB). 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the claim 
must be submitted to the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the 
diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for radiologic examination, chest (71045) provided September 7, 2021 to 
September 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on July 27, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
 
 
 
 
 
  
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
diagnosis code. 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 pay for the ambulance transport rendered on 
July 27, 2021.
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. The Plan denied your request. The Plan says the LTACH would add no additional services.
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 physician reviewer found that the enrollee was admitted to the acute care hospital with COVID-19 pneumonia, acute respiratory failure, and candida esophagitis requiring high flow oxygen. Her hospital course was complicated by bacterial pneumonia, diarrhea, requiring intravenous antibiotics. Recent notes describe the enrollee as still requiring high flow oxygen and not having had multiple unsuccessful weaning attempts. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injection (ESI) services.
You asked the Plan to pre-approve ESI services. You say that the office notes provided support the need for the
injection services in dispute. The Plan denied your request. The Plan says the requested injection services are
not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are contraindicated for
axial or nonspecific pain without radiating pain
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 ESI services. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the enrollee has documented axial pain
and responded well to diagnostic medial branch blocks (MBBs.) There is no documentation of radicular pain.
The requested injection services are 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 ESI services have not been met. Therefore, we decided that the Plan does not
have to pre-approve epidural steroid injection (ESI) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation for high dose rate brachytherapy to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an evaluation with an OON provider. You say that you would like the Plan
to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither
emergent nor urgent to seek out-of-network care. The Plan says that the enrollee is approved to see a tertiary
level in-network provider who can provide the same care and treatment you are requesting.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an evaluation for high dose rate brachytherapy to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to reduce the copayment for the hospital services.

You asked the Plan to reduce the copayment for the hospital services. You say that you were sent to the emergency room by your colonoscopy doctor. You also say that you were not admitted to the hospital. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There are no medical records showing you were admitted as an inpatient. You confirmed you did receive emergency room services. Therefore, we decided that the Plan has to reduce the copayment for the hospital services to the $90 copayment for an emergency room visit.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Prolia is supported for postmenopausal osteoporosis at high risk for fracture when the documentation includes qualifying information.
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 Prolia. Our reviewer says that the requested drug, Prolia, is not medically necessary. Our physician reviewer found the record indicates that the enrollee has age related osteoporosis with high risk of fracture. The record does not indicate that the enrollee has had any fractures, nor does it indicate that the results of previous osteoporosis treatment. The elements of the coverage criteria are not satisfied. Therefore, the requested drug, Prolia, cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Specifically, the file shows that the provided documentation does not indicate that the enrollee has previously received osteoporosis treatment. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is not under the care of a physician for the services. 
 
 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 the requested services. Our physician 
reviewer found that the enrollee does not have documented, ongoing, home health occupational therapy skilled 
therapy needs. His baseline is unclear. The progress made to date is unclear. The need for ongoing therapy, 
restorative, or maintenance, is not documented. As such, the requested, ongoing, home health occupational 
therapy services are not medically necessary or reasonable. 
 
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 home health occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic injection (62320) provided on October 18, 
2021. 
 
 
You asked the Plan to pay for the therapeutic injection. 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 medical necessity of the service billed. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the therapeutic injection have been 
met. Specifically, the documentation submitted does not include any medical records. Therefore, we decided 
that the Plan does not have to pay for the therapeutic injection (62320) provided on October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy coded as 29875-59 provided on August 
31, 2021. 
 
You asked the Plan to pay for the knee arthroscopy. You say that the documentation supports the billing of the 
59 modifier to represent this as a separate and distinct procedure. The Plan denied your request. The Plan says 
the use of the 59 modifier is not supported by the documentation submitted. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 knee arthroscopy Our reviewer says that 
the documentation does not support the claim as billed. Our physician reviewer found that the operative report 
does not support a distinct procedure service.  Per Medicare coding regulations: "Arthroscopic synovectomy of the knee may be reported with CPT codes 
29875 (Limited synovectomy, separate procedure) or 29876 (Major synovectomy of two or three 
compartments). A synovectomy to clean up a joint on which another more extensive procedure Revision 
Date (Medicare): 1/1/2022 IV-7 is performed is not separately reportable. CPT code 29875 shall not be 
reported with another arthroscopic knee procedure on the ipsilateral knee. CPT code 29876 may be reported for 
a medically reasonable and necessary synovectomy with another arthroscopic knee procedure on the ipsilateral 
knee if the synovectomy is performed in 2 compartments on which another arthroscopic procedure is not 
performed. For example, CPT code 29876 shall not be reported for a major synovectomy with CPT code 29880 
(Knee arthroscopy, medial and lateral meniscectomy) on the ipsilateral knee, since knee arthroscopic 
procedures other than synovectomy are performed in 2 of the 3 knee compartments." 
 
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 knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pay for the knee arthroscopy coded as 29875-59 provided on August 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on August 14, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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. 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 the services (70450) provided on August 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided by an out-of-network 
provider on May 13, 2020, to May 20, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that this inpatient stay was medically necessary. 
The Plan denied your request. The Plan says the principal diagnosis code is not supported.  
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 A41.9 - sepsis unspecified organism. 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 inpatient hospital care. Our physician reviewer found 
medical records do not support the billing of principal diagnosis code, A41.9 sepsis unspecified organism.  
 
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 inpatient hospital care provided by an out-of-network provider on May 13, 2020, to May 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound rendered on September 25, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 76870 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 pay for the ultrasound rendered on September 25, 2021.