Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endosteal implants (D6010), implant supported crowns (D6065), implant removal (D6100), implant supported interim fixed denture (D6119), extractions (D7210), complicated suture (D7912) and cone beam image capture (D0367) provided on March 17, 2021.  You asked the Plan to pay for the dental services. You say that these services were necessary, and you want to know if they can be covered by your medical insurance. The Plan denied your request. The Plan says Original Medicare only covers limited dental care for specific situations. Your supplemental benefit covers a maximum of $1,300 for dental care. You have exceeded this maximum and are responsible for the remaining costs.  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. The Plan covers a maximum of $1,300 of supplemental dental care per year.  Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that the Plan has already paid the full $1,300 maximum for your dental care in 2021, and these services were provided in excess of this amount. Therefore, we decided that the Plan does not have to pay for the endosteal implants (D6010), implant supported crowns (D6065), implant removal (D6100), implant supported interim fixed denture (D6119), extractions (D7210), complicated suture (D7912) and cone beam image capture (D0367) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on August 23, 2021.  You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.  The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  The medical records in this case do not meet Medicare's documentation requirements.  Specifically, there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  

You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is recommended to improve mobility and safety prior to returning home to family. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Inflectra.  You asked the Plan to pre-approve Inflectra. You say that this drug is medically reasonable and 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 Inflectra. Our reviewer says that this drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 3-month trial of non-biologic treatment and documentation that the patient is taking Methotrexate or the request must clearly show the reason patient cannot take methotraxate before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Inflectra have not been met. Therefore, we decided that the Plan does not have to pre-approve Inflectra.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. The Plan denied your request. The Plan says IRF care is not medically reasonable and necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient was admitted for a rectal abscess and Clostridium difficile colitis. Medical problems are stable. There are no complex nursing or rehabilitation needs.  The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 23, 2021.  You asked the Plan to pay for periodontal maintenance. You say that because dental care is not covered by Original Medicare, there was no advantage in enrolling in the Medicare program. Had you been informed that this decision would have affected payment to you and reimbursement to your patients, this choice would have been reconsidered. The Plan denied your request. The Plan says the enrollee's contract states that dental care must be performed by a provider who participates in Original Medicare. The provider in this case does not participate in the Medicare program; therefore, this service is denied.  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. The Plan requires that supplemental dental care be performed by a provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from providers who have opted out of Medicare are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 5, 2021.  You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 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 ultrasound services provided to the enrollee on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the cardiac rhythm monitor insertion (33285).  You asked the Plan to pre-approve the cardiac rhythm monitor insertion (33285). You say that there is a concern that the member has atrial flutter and has had transient disorientation. You say that you would like to implant a loop recover for long-term monitoring. The Plan denied your request. The Plan says the insertion of subcutaneous cardiac rhythm monitor is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the cardiac rhythm monitor insertion (33285). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided to suggest a history of unexplained syncope or any other apparent indication for an Implanted Loop Reader (ILR). Atrial fibrillation was documented, and anticoagulation initiated to minimize thromboembolic stroke risk. In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this patient's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiac rhythm monitor insertion (332285) have not been met. Therefore, we decided that the Plan does not have to pre-approve the cardiac rhythm monitor insertion (33285).
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office visits. You say that this care is medically necessary. The Plan denied your request. The Plan says care with an OON provider is not medically reasonable and necessary.  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 office visits to be provided 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 September 22, 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 September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services (86077-59) provided on September 24, 2021.
You asked the Plan to pay for the blood bank physician services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed services exceed the MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services (86077-59) provided on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 6, 2020.
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 do not show that the specimen was collected in laboratory setting. 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 August 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 9,
2021.
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service.
The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding
regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services provided to the enrollee on October 9, 2021.
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 September 30, 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 September 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 18, 2021.
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says the service is not supported without the required documentation.
The Plan must follow Medicare rules. The rules say that if consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. This does not apply if the physician referred the patient to the CP. We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the services at issue. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the psychotherapy (90834) provided on June 2, 2021.  You asked the Plan to pay for the psychotherapy (90834). You say that the attached medical records prove the medical necessity, and the claim should be processed toward payment. The Plan denied your request. The Plan says that a provider must attempt to consult the attending or primary care physician about the services furnished.  The Plan must follow Medicare rules. Medicare rules say that the services of a Clinical Social Worker (CSW) may be covered when certain criteria are met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy (90834) have been met. Specifically, the claim indicates that these services were rendered by a CSW. There is no Medicare criteria indicating that a CSW must communicate with the member's treating physician. The Plan has not forwarded any additional evidence to substantiate why these services are not payable. Therefore, we decided that the Plan has to pay for the psychotherapy (90834) provided on June 2, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive metabolic panel (80053), lipid panel
(80061), thyroid stimulating hormone (84443) and complete blood count (85025) provided on June 30, 2021.
You asked the Plan to pay for the comprehensive metabolic panel, lipid panel, thyroid stimulating hormone and
complete blood count. You say that you would like reconsideration based on the records submitted. The Plan
denied your request. The Plan says Medicare does not cover these services for screening purposes.
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, the comprehensive metabolic panel, lipid panel, thyroid stimulating hormone
and complete blood count, 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 comprehensive
metabolic panel (80053), lipid panel (80061), thyroid stimulating hormone (84443) and complete blood count
(85025) provided on June 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 home physical therapy visits.  You asked the Plan to pre-approve 10 home physical therapy visits. You say that the patient was referred to home health following a hospital stay due to extreme shortness of breath as a result of the coronavirus. You say that continued physical therapy is needed to improve gait, endurance and improve the patient's ease with activities of daily living. The Plan denied your request. The Plan says the medical records do not clearly document a need for the services of a skilled physical therapist.  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 10 home physical therapy visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found that the member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations and should be independent with a home exercise program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 home physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 home physical therapy visits.