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

We decided that the Plan does not have to pay for the surgical services rendered on September 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 procedure code 42950 is 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 42950 is pharyngoplasty (plastic or reconstructive operation on pharynx). We find that CPT code 42950 is not supported in the medical record. Specifically, there is no documentation of a plastic or reconstructive pharyngoplasty. 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 September 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for filters (A7507) provided on December 18, 2020. 
 
You asked the Plan to pay for filters. You say that this is supported in the records. The Plan denied your 
request. The Plan says this is not supported by the proof of delivery. 

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The itemized 
delivery tickets in the file are dated with various dates in 2021 rather than the billed date of service, December 
18, 2020. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for filters (A7507) provided on December 18, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on May 25, 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 drug testing (80307) rendered by the out-of-network (OON) provider on May 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens (V2203), anti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens (V2782), and frames (V2020) provided March 24, 2021.

You asked the Plan to pay for the routine eyewear. You say that you were not aware that you had to see a network provider. The Plan denied your request. The Plan says the routine eyewear is not covered because it was purchased out-of-network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are obtained from a provider in the Plan's vision vendor network. 

We looked at the file and the Plan's rules. In this case you purchased routine eyewear from a provider who is not in the Plans vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens (V2203), anti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens (V2782), and frames (V2020) provided March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (72192) provided on June 7, 2021.
You asked the Plan to pay for CT scan 72192. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 72192 has a procedure-to-procedure (PTP) edit modifier of 1 with code 74176 meaning this code is not separately payable without an appropriate 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 CT scan 72192 has a bundled relationship with code 74176 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed on this code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (72192) provided on June 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept, rural area (A0432), provided on
December 27, 2020.
You asked the Plan to pay for the ambulance service. You say that you were throwing up blood. You say that 2
ambulances arrived. You say that you were taken to the hospital. You also say that the paramedic should get
paid. The Plan denied your request. The Plan says there is no contract that exists between the basic life support
(BLS) and advanced life support (ALS) providers.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMTParamedic
only in certain circumstances. Medicare allows ALS paramedic intercept services only when the
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow
the volunteer ambulance company to bill for the transport or BLS services.
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic
intercept, rural area (A0432), provided on December 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on March 4, 2020, and 
September 1, 2020. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered 
under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on March 4, 
2020, and September 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95861, 95937
and G0453) provided on February 23, 2021.
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that you would like
reconsideration because these services were requested by an in-network surgeon and were medically necessary.
The Plan denied your request. The Plan says the billed services were not medically necessary for the member's
condition.
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 intraoperative neuromonitoring services.
Our reviewer says that intraoperative neuromonitoring services are not readily supported for use in lumbar
spine procedures.
Our physician reviewer found given the conflicting evidence to date and the overarching consensus that further study is necessary to evaluate the use of IONM in lumbar spine surgery, the requested service is not supported as medically necessary. 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 intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95861, 95937 and G0453) provided on February 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided on February 17, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. Cost sharing is waived if you are admitted into the hospital. 

You have been asked to pay a $90 copayment for the emergency department visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical facet joint radiofrequency ablation procedures.
You asked the Plan to pre-approve cervical facet joint radiofrequency ablation procedures. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria is 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 cervical facet joint radiofrequency ablation procedures. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have only had one set of diagnostic injections and has not undergone a prior RFA procedure to the same level. The review has determined that you do not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical facet joint radiofrequency ablation procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical facet joint radiofrequency ablation procedures.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 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 a skilled nursing setting and
should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transesophageal echocardiography (93313) provided August
17, 2020.
You asked the Plan to pay for the transesophageal echocardiography. You say that medical documentation has
been provided again to support these services provided. The Plan denied your request. The Plan says the
documents do not support the procedure or service was distinct or independent from other services performed,
therefore, the use of the 59 modifier is 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, we have confirmed that code the
transesophageal echocardiography has a bundled relationship with code 00534 and cannot be paid as billed.
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for transesophageal echocardiography
(93313) provided August 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered on January 20, 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 claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. The records support only one billed unit of these services, which has been paid. 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 electrical stimulation rendered on January 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 31,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on January 31,
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 June 11, 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 June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on July 27, 2020.
You asked the Plan to pay for the testing services. You say that the records prove medical necessity. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing panels.
The Plan follows Medicare rules. The rules explicitly say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file and the rules. In this case, there are insufficient medical records to show that the indications for coverage were met. There are no medical records to show that the enrollee had a history of chest pain, suspected anginal equivalent to chest pain, or a high risk of CAD. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services.
You asked the Plan to pay for out of network services. . You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 {{enter specific services at issue}} provided on February 16, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 13, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that the enrollee has not received sufficient rehabilitation
services and should not be sent home. The Plan denied your request. The Plan says the stay is not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental
medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and
improved; however, their function had plateaued, and the enrollee did not require any further inpatient skilled
rehab services. The enrollee's function was at or near their new baseline level of function and the enrollee
could be discharged to a lower level of care for further services. The enrollee required custodial services. The
denial for further inpatient skilled care is upheld.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care from October 13, 2021, forward.