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

We decided that the Plan does not have to pay for the dialysis service (90962) rendered by the out-of-network (OON) provider on January 31, 201.
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, pre-approved care, and for enrollees who utilize the POS benefit with a primary care
physician referral.
The enrollee's primary care physician did not issue a referral for the service provided in this case. The Point-of-
Service (POS) benefit allows an enrollee to access services from non-network providers. Similar to the referral
requirements for care received from network providers, enrollees must get a referral from their PCP prior to
getting care from out-of-network providers. If the enrollee does not get a referral, they will have to pay the full
cost of the services provided. Additionally, 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 dialysis service (90962) rendered by the out-of-network (OON) provider on January 31, 201.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy provided on January 11, 2021 by an out-of-network (OON) provider.
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 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 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 physical therapy provided on January 11, 2021
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 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 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head).
Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 5, 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 codes 14301 and 14302 are 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 code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). We find that CPT codes 14301 and 14302 are not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement of any area, 30.1 sq cm to 60.0 sq cm to support
code 14301. Given that the primary procedure code is not supported, add-on code 14302 is also not supported. 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 surgical services rendered on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the incisional biopsy of oral soft tissue (D7286) provided
on May 3, 2021.
You asked the Plan to hold you harmless for the oral biopsy. You say that this service was medical in nature
and provided to see if your cancer, for which you are currently being treated, had spread to your mouth. The
Plan denied your request. The Plan says that this service is not covered by your supplemental dental benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules. The rules also say that Medicare plans must make reasonable and diligent efforts
to gather and forward information to the IRE.
You were referred for the oral biopsy by a contract provider to see if your cancer had spread to your mouth.
The file does not show that the Plan provided notice that the oral biopsy would not be covered as a medical
service.
The Plan did not request records from the contracted provider to verify that this service is medical in nature,
and no documentation was provided to show that you were notified that this service would not be covered for
any reason. Under Medicare rules, this means the oral biopsy is considered approved by the Plan. Therefore,
we decided that the Plan has to hold you harmless for the incisional biopsy of oral soft tissue (D7286) provided
on May 3, 2021.
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 the office visits, physical therapy treatment modalities, and
additional services (coded as 99203, 97039, 97140, and 99072) provided from April 19, 2021, to May 17,
2021.
You asked the Plan to pay for the non-spinal manipulation services. You say that this is a network chiropractor
so the services should be covered. The Plan denied your request. The Plan says the spinal manipulations were
approved for payment. However, the other services are not covered when provided by a chiropractor.
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 office visits, physical therapy treatment modalities, and additional services
(coded as 99203, 97039, 97140, and 99072) provided from April 19, 2021, to May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Corus CAD testing rendered on July 20, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, Corus CAD, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
Corus CAD testing rendered on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 4, 2020.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the travel and lodging expenses related to your hospital stay incurred from February 23, 2021, through April 14, 2021.
You asked the Plan to pay for the travel and lodging expenses. You say that your daughter needed to stay with near the facility you were in as you were not able to manage your own care. You feel that reimbursement would be appropriate since you had no choice but to be treated at this facility. The Plan denied your request. The Plan says the expenses have been reimbursed during the time that a transplant was planned. However, the travel/lodging coverage does not apply to non-transplant related care.
The Plan must follow Medicare rules. Medicare rules say that health plans are only required to provide travel and lodging coverage when the enrollee is receiving transplant care further from home than is normally required for Medicare patients. In this case, by the dates in question, the care being provided was no longer organ transplant related. This
means that the travel and lodging expenses were no longer reimbursable. Therefore, we decided that the Plan does not have to pay for the travel and lodging expenses related to your hospital stay incurred from February 23, 2021, through April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services provided on November 12, 2020, billed with code 99100.
You asked the Plan to pay for the special anesthesia services. You say that the documentation supports that payment should be made. The Plan denied your request. The Plan says this is not a payable code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule, meaning that payment for this service is always bundled in other payments made to the provider. Based on this information, we decided that Medicare rules for coverage of the special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on November 12, 2020, billed with code 99100.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections of the cervical or thoracic (CPT code(s): 64491 and 64490).
You asked the Plan to pre-approve the injections. You say that you have had multiple cervical interlaminar epidural steroid injections which have provided relief of the radicular pain, but not of the localized neck pain. You state the most recent assessment also shows you have significant increased pain with facet loading on the
left and the office plans to perform this injection and possibly another depending on level of relief with a subsequent radiofrequency ablation. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 injections. Our physician reviewer found the pain does not appear to be primarily axial and you have subjective complaints consistent with radiculopathy. The pain does not appear to be primarily axial and, you have subjective complaints consistent with radiculopathy. The review has determined that you do not meet LCD criteria for the services. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections of the cervical or thoracic (CPT code(s): 64491 and 64490).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency anesthesia services rendered on March 24, 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 are 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 99140 (emergency anesthesia) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia services rendered on March 24, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gammaked.
You asked the Plan to pre-approve Gammaked. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gammaked. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has chronic inflammatory demyelinating polyneuritis. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gammaked have not been met. Therefore, we decided that the Plan does not have to pre-approve Gammaked.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January
20, 2021 through January 26, 2021.
You asked the Plan to pay for the SNF care provided from January 20, 2021 through January 26, 2021. You say
that the SNF services provided from January 20, 2021 through January 26, 2021 was medically necessary. The
Plan denied your request. The Plan says the enrollee did not meet Medicare criteria for the SNF services
provided from January 20, 2021 through January 26, 2021.
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 pay for the SNF care provided from January 20,
2021 through January 26, 2021. Our reviewer says that daily skilled services are not necessary. Our physician
reviewer found based on the medical records provided there is no documentation that the enrollee required
skilled nursing services or skilled therapy services from January 20, 2021 through January 26, 2021. This
enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting from January
20, 2021 through January 26, 2021. There were no skilled nursing needs or therapy needs documented in the
available records for dates January 20, 2021 through January 26, 2021.
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 SNF care provided from January 20, 2021 through January 26, 2021 have
not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF)
care provided from January 20, 2021 through January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient evaluation and management (EM) services provided on June 7, 2021, billed with code 99205.
You asked the Plan to pay for the new patient EM services. You say that this is correctly billed. The Plan denied your request. The Plan says the enrollee was seen by Internal Medicine physicians in the group practice previously. As such, the new patient code is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers may bill a new patient visit only if the patient has not received any face-to-face EM services from a provider of the same specialty in a group practice with the past 3 years.
In this case, although this was the first visit with this provider, the enrollee has had two other face to face EM services with Internal Medicine physicians at this group practice within the last 3 years. As such, the new patient EM code is not appropriate. Therefore, we decided that the Plan does not have to pay for the new patient evaluation and management (EM) services provided on June 7, 2021, billed with code 99205.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on May 24, 2021.
You asked the Plan to pay for the non-emergent ambulance services. You say that the enrollee was transported from a skilled nursing facility to a hospital due to chronic renal failure and acute respiratory failure. These services were medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for non-emergent ambulance transportation were not met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the criteria for non-emergent ambulance transportation are not met. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on the date in question. The documentation does not support that the enrollee required the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on May 24, 2021. The documentation does not support that the ambulance transport on this date was medically reasonable and necessary for 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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on May 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the unattended electrical stimulation services provided on February 4, 2021, billed with code 97014.
You asked the Plan to pay for the electrical stimulation services as billed. You say that this code should be paid. The Plan denied your request. The Plan says this is not a code that can be paid by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code 97014 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the unattended electrical stimulation services provided on February 4, 2021, billed with code 97014.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on January 12, 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 are not covered.
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 codes 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 units of each 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 pain management services rendered on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies and specimen handling rendered on May 4, 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 are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. 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 A4556 (electrodes, per pair) has a status
indicator of P and code 99000 (specimen handling services) a status indicator of B. These codes do not have separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the supplies and specimen handling rendered on May 4, 2021.