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

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0075 provided on August 27, 2021.

You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. 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 R0075 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen.

We find that CPT code R0075 is not supported in the medical record. Specifically, this transportation service was reported but did not report a setup code, which does not follow standard coding rules. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0075 provided on August 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) (93042) provided on June 11, 2021.

You asked the Plan to pay for the rhythm ECG. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the claim has not been billed in accordance with Medicare coding regulations.

The Plan must follow Medicare rules. The 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. In this case, no medical records were provided to corroborate the claim as billed. Based on this information, we decided that Medicare rules for coverage of the rhythm ECG have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) (93042) provided on June 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health, physical therapy visits
(G0151).
You asked the Plan to pre-approve the home physical therapy visits. You say that the enrollee has not met their
goals and is debilitated due to chronic diagnosis. The Plan denied your request. The Plan says medical
necessity cannot be established for continued home health physical therapy level of coverage.
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 home physical therapy visits. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee does not have documented, ongoing, home health/physical
therapy needs. The enrollee is functioning at a level commiserate with a lower level of care (i.e. HEP,
outpatient therapy). As such, the requested, ongoing home health physical therapy is 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 home physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 4 additional home health, physical therapy visits (G0151).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient radiology services provided to the enrollee on August 4, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider needs to submit the claim to the primary insurance.

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 directed the provider to send the bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for outpatient radiology services provided to the enrollee on August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Orthovisc for the enrollee.
You asked the Plan to pre-approve a tier exception. You say that a tiering exception is necessary for the
enrollee. The Plan denied your request. The Plan says that tier exceptions (co-pay reductions) are not available
for drugs/devices covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D
drugs.
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for
coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to preapprove
a tier exception for Orthovisc for the enrollee.
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 records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute
care and does not require transfer to an LTACH.

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 the enrollee appears to be improving and requires only short-term additional acute
care services that can be safely administered at the current facility. The enrollee does not require services at the
LTACH that are not already available and covered at the current facility. Transfer to an LTACH is not
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be
considered soon 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (S0020) provided to the enrollee on May
24, 2021.
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request.
The Plan says this code is not valid for Medicare purposes.
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 S0020 is "Injection, bupivicaine hydrochloride, 30 ml."
We find that procedure code S0020 is not supported in the medical record. Specifically, this code has a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the injection
have not been met. Therefore, we decided that the Plan does not have to pay for injection services (S0020)
provided to the enrollee on May 24, 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 would benefit from a transfer to an LTACH as she requires high nursing needs that cannot be met in a lower level of care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.
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 the enrollee appears to be improving gradually and requires only short-term additional acute care services including additional weaning that can be safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered soon 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 20, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code.

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 drug testing services provided on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 16,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied codes remain not supported.
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 12001:
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities
(including hands and feet); 2.5 cm or less
CPT 11740:
Evacuation of subungual hematoma
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 the provider reported CPT 26750 -
Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each. This service should
be reported with an appropriate modifier, as this procedure would not be considered closed treatment. As CPT
12001 was incorrectly reported, CPT 11740 would also not be covered.
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 surgical services provided to the enrollee on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) provided September 30, 2021.
You asked the Plan to pay for the chiropractic services. You say that without the help of this doctor, you would not be able to walk. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
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 to correct subluxation. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) provided September 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance imaging (MRI).

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this location is out-of-network.

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 out-of-network referral for magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure 00902) provided to the enrollee on July 15, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says no supporting documentation has been received.

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 00902 is "Anesthesia for; anorectal procedure." 

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 the documentation consists of Provider remittance advice for procedure CPT 00902 with modifier 59. No other codes billed were included in documentation. Therefore, modifier -59 cannot be verified, as to what it is a distinct service from. 

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 anesthesia services (procedure 00902) provided to the enrollee on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing radiographic images (x-ray) (D0274), provided on November 15, 2021.

You asked the Plan to pay for the bite wing x-rays. You say that the service is medically necessary. The Plan denied your request. The Plan says you have exhausted your Plan's benefit for this 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 requested items or services are not among those covered under this benefit. Specifically, records indicate you received bitewing x-rays on May 10, 2021. The Plan allows one bitewing x-ray a year. This means you have exhausted the Plan's benefit for this service and are responsible for the additional service. Therefore, we decided that the Plan does not have to pay for the bitewing radiographic images (x-ray) (D0274), provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to
the enrollee on May 18, 2021.

You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your
request. The Plan says the testing was not initiated by the provider.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not indicate how the test results will assist in managing the enrollee's 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and complete lower
denture (D5120).
You asked the Plan to pre-approve the dental services. You say that you received dentures in 2019. You say
that they do not fit correctly. You say that you returned them to have them fixed. You say that they broke. You
also say that you are no longer with that office and are unable to wear them. The Plan denied your request. The
Plan says dentures 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 dentures are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete
upper denture (D5110), and complete lower denture (D5120).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Tecentriq (J9022) and Mvasi (Q5107).
You asked the Plan to pre-approve Tecentriq and Mvasi. You say that the requested drugs are a medical necessity for you. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested drugs have not been prescribed to treat a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Tecentriq and Mvasi. Our reviewer says that the requested treatment is medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Tecentriq and Mvasi is FDA-approved for your diagnosis as you have not received prior systemic therapy but only localized therapy. The documentation supports that the requested drugs are safe and effective and otherwise reasonable and necessary for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq and Mvasi have been met. Therefore, we decided that the Plan has to pre-approve treatment with Tecentriq (J9022) and Mvasi (Q5107).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided to the enrollee on
August 16, 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 despite multiple outreaches by the plan, the provider has not submitted any clinical
records to support the medical necessity of this service.

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. Based on this information, we decided that Medicare rules for the
services at issue have not been met. Specifically, the case file did not contain medical records for the billed
services. Without the medical records, the billed services cannot be verified. Therefore, we decided that the
Plan does not have to pay for pain management services provided to the enrollee on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5212).
You asked the Plan to pre-approve the dental service. You say that you are having issues chewing your food. You also say that you really need this. The Plan denied your request. The Plan says partial lower denture is not listed as 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 partial lower denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5212).