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

We decided that the Plan does not have to pay for the abdominal ultrasound interpretation provided on
September 28, 2021.
You asked the Plan to pay for the ultrasound interpretation. You say that this was billed correctly and should be
paid. The Plan denied your request. The Plan says the Column 2 code was not billed with the required modifier.
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 76705
is a column II code in relation to column I code 93976. 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 abdominal ultrasound interpretation provided
on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass fitting provided on July 15, 2021.
You asked the Plan to pay for the fitting. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Neither Medicare
nor the Plan covers this eyeglass fitting. Therefore, we decided that the Plan does not have to pay for the
eyeglass fitting provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided October 18, 2021.

You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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. No medical records were submitted to support the services. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided October 18, 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 the enrollee is stable and will require extended acute care. The Plan denied your request. The Plan says the enrollee is unstable for transfer.  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 in this case, the enrollee was admitted to the acute care hospital for sepsis, pneumonia, right foot osteomyelitis, a urinary tract infection and a heart attack. The enrollee is not noted to be on mechanical ventilation. She is receiving appropriate care at the present acute care hospital. She does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary, for the diagnosis and condition of the enrollee.  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 pay for the shoulder surgery procedures provided on 7/28/2021 billed with 24320 and 29823.  You asked the Plan to pay for the services. You say that the provider feels these codes were correctly reported. The Plan denied your request. The Plan says the report does not support that the services described by these codes were performed.  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 the denied codes is:  CPT 24320:  Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure)   CPT 29823:  Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found in terms of CPT 25320, the operative report does not support a muscle transfer elbow to shoulder. In terms of CPT 29832, the operative report documents debridement of the Labrum and rotator cuff, which does not support extensive debridement 3 or more discrete structures. Therefore, this procedure is not supported.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder surgery procedures provided on 7/28/2021 billed with 24320 and 29823.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311).  

You asked the Plan to pre-approve a power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311). You say that the requested power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311) are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311). 

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 power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311). Our reviewer says that the enrollee does not meet criteria for the requested power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311). Our physician reviewer found based on the medical records provided by the enrollee's treating physician there is no documentation that the enrollee meets the above LCD criteria for the requested power seat tilt (E1002). Records from the treating physician do not document the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or she utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or the power seating system is needed to manage increased tone or spasticity.   

Based on the medical records provided by the enrollee's treating physician there is no documentation that the enrollee meets the above LCD criteria for the requested headrest (E0955) as the enrollee does not meet criteria for the power tilt feature.   

Based on the medical records provided by the enrollee's treating physician there is no documentation that the enrollee meets the above LCD criteria for the requested swing away (E1028) as the enrollee does not meet criteria for the power tilt feature.   

Based on the medical records provided by the enrollee's treating physician there is no documentation that the enrollee meets the above LCD criteria for the requested electronic components (E2311) as the enrollee does not meet criteria for the power tilt feature.  

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 power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat tilt (E1002), headrest (E0955), swing away (E1028), and electronic components (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the endosteal implants. You say that you would like the implants covered. The Plan denied your request. The Plan says implants 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 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on May 19, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says air ambulance was not medically necessary.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee transported by air ambulance from a hospital in Mt. Graham, AZ to a hospital in Mesa, AZ for closer family support nearby. The review has determined that the documentation did support that the patient suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation did not support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on July 12, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says your plan covers ambulance transportation only when you are actually transported by
ambulance. Since you were not transported by this ambulance, the service is not covered by your Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on July 12, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (D4921).
You asked the Plan to pre-approve gingival irrigation. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve gingival irrigation - per quadrant (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0898).

You asked the Plan to pre-approve a power wheelchair (K0898). You say that the requested power wheelchair (K0898) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair (K0898).

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 power wheelchair (K0898). Our reviewer says that the enrollee does not meet criteria for the requested power wheelchair (K0898). Our physician reviewer found based on the medical records provided by the enrollee's treating physician, there is no documentation that the enrollee meets the above LCD criteria for the requested power wheelchair (K0898). Records form her physician do not document that the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Records from her physician do not document that the enrollee's mobility deficit cannot be helped by the use of a walker or manual wheelchair or that she can safely operate a power mobility device. 

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 power wheelchair (K0898) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0898).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87631) provided June 5, 2020.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and is 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, we have confirmed that code 87631 has a bundled relationship with code 87633. 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 lab services (87631) provided June 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90837) provided July 13, 2021.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 

We find that CPT code 90837 is not supported in the medical record. Specifically, the claim was submitted with an outpatient place of service (11, office setting), however the records show the enrollee was an inpatient at the time services were rendered. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837) provided July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing.

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is non-covered.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. 

We looked at the file and Medicare rules. This service is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 22, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant
(D6010).
You asked the Plan to pre-approve endosteal implants. You say that you want to have a healthy mouth and
avoid infections. The Plan denied your request. The Plan says implant 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 are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services at an out-of-capitation provider.
You asked the Plan to pre-approve these services. You say that the capitation site is too far. The Plan denied
your request. The Plan says the services are available at the capitation site.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that enrollees must use the PCP's designated site for laboratory services to receive in-network
coverage.
The requested provider in this case is not the PCP's designated site. The services are available at the PCP
designated site. 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 laboratory services at an out-of-capitation
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90471, 90750) provided October 1, 2021.

You asked the Plan to pay for the shingles vaccine. You say that this vaccine should be covered. The Plan denied your request. The Plan says this vaccine is covered under the Part D benefit and not the Part B medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90471, 90750) provided October 1, 2021.

Benefits for the shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 12, 20, and 21, and a filling (D2331) for tooth # 11.

You asked the Plan to pre-approve the dental services. You say that you require these services as a result of radiation treatment. You also say that you feel these services should be covered under medical. The Plan denied your request. The Plan says you are not enrolled in the optional supplemental dental rider. The Plan also says that crowns and fillings are not covered.

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 crowns and filling are not among those covered under this benefit. Additionally, the services you are asking the Plan to pre-approve 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 pre-approve crowns (D2740) for teeth # 12, 20, and 21, and a filling (D2331) for tooth # 11.