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

We decided that the Plan does not have to pay for the laboratory testing provided on January 18, 2021.

You asked the Plan to pay for the laboratory testing. 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 supported by the documentation.

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 81162 is BRCA1 (BRCA1, DNA repair associated),
BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full
sequence analysis and full duplication/deletion analysis (i.e., detection of large gene rearrangements).

We find that CPT code 81162 is not supported in the medical record. Specifically, the documentation shows
that a panel test was performed. There is a more appropriate code to be billed for the service performed. Based
on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on January 18,
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/investigational. 
 
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 a Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is considered experimental/investigational since the role 
of the Vertiflex spacers has not been defined by specialty societies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy and the ultrasound therapy services provided on July 23, 2020.
You asked the Plan to pay for the electrical stimulation therapy and the ultrasound therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy and the ultrasound therapy services provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).

You asked the Plan to pre-approve the total electric hospital bed. You say that there was a mistake on the Plan's part as they put a different facility on the denial so when you called to request a copy of the denial letter you were told the Plan cannot send it to you. You state need a copy of this so that you can move on to the next payer to try to secure funding for this client. The Plan denied your request. The Plan says Medicare will not pay for a total electric bed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after October 1, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary and reasonable. The Plan denied your request. The Plan says the criteria for SNF care are no longer met in this case.

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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on April 22, 2021, by an OON
provider.
You asked the Plan to pay for the injection. You say that the service was 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 injection provided on April 22, 2021, by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on April 8, 2021 by an 
OON provider. 
 
You asked the Plan to pay for the chiropractic services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 

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 the chiropractic services provided on April 8, 2021 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391) and root canal (D3330) provided on
March 11, 2021.
You asked the Plan to pay for the dental services. You say that you feel that the services you received were
surgical. You also say that you are trying to save the few teeth that you have left. The Plan denied your request.
The Plan says routine dental services are not covered by Medicare or the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the filling (D2391) and root
canal (D3330) provided on March 11, 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. You say that LTACH can provide continuation of care that a lower level would not be able to provide. The Plan denied your request. The Plan says criteria for admission to the LTACH have 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 that there is no documentation provided indicating medical necessity for admission to an LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pharmacogenetic testing and the cardiovascular risk assessment testing provided on April 12, 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.
The Plan follows Medicare rules. The rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. In this case, the medical records provided do not confirm that the labs were billed correctly. The rules also explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing and the cardiovascular risk assessment testing provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision service provided on February 24, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the vision services provided by an OON provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 

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 the vision service provided on February 24, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640) provided on January 26, 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 a skilled nursing facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640) provided on January 26, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a screening CT colonography (74263).
You asked the Plan to pre-approve a screening CT colonography. You say that you are unable to have a regular
colonoscopy due to a risk of rupture. The Plan denied your request. The Plan says rules for coverage have not
been met because the requested procedure is not a Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that CT colonography is not reimbursable when used
in the absence of signs or symptoms of disease.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a screening CT colonography have not been met. Specifically, the requested procedure is a
screening procedure used in the absence of signs or symptoms of disease. Therefore, we decided that the Plan
does not have to pre-approve a screening CT colonography (74263).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation bilateral procedures on 3 levels.

You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636). You say that the enrollee needs the procedures for pain relief. The Plan denied your request. The Plan says guidelines have not been met.

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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636). Our reviewer says that it is not medically necessary or reasonable for this enrollee to have the injections as requested. Our physician reviewer found no repeat MBBs have been performed and there is no documentation that a three level RFA is warranted. Therefore, facet joint intervention for Pain Management Guidelines have not been met and the denial of the bilateral RFA, has been upheld.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation bilateral procedures on 3 levels.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 20, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. We find that the place of service was listed on the billed claim as an independent laboratory. The records provided do not indicate the specimen was obtained at the independent laboratory at issue. 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 drug testing services provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue exam by a pathologist (88305) provided on March 9, 
2021, by an OON provider. 
 
You asked the Plan to pay for the tissue exam. You say that your primary care physician was not involved with 
this procedure. You also say that a biopsy was performed by your periodontist. The Plan denied your request. 
The Plan says this service was rendered by a non-participating provider, and there is no referring provider. The 
Plan also says that this service was not 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 
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 tissue exam by a pathologist (88305) provided on 
March 9, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on May 17, 2021.

You asked the Plan to pay for the dental service. You say that your policy says that your plan will pay for repair or realignment of a partial. You say that this does not seem right as you need to have a partial before you can have it repaired or aligned. You also say that this should be covered or you will reconsider your insurance. The Plan denied your request. The Plan says partial lower denture 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 partial lower denture is not among those covered under this benefit. Additionally, the record shows that you signed a financial agreement acknowledging responsibility for services that are not covered. Therefore, we decided that the Plan does not have to pay for the partial lower denture (D5214) provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on December 2,
2020, by an OON provider.

You asked the Plan to pay for the office visit and related services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.

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 the office visit and related services provided on
December 2, 2020, by an OON provider.