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

We decided that the Plan does not have to pay for the computed tomography (CT) scan of head or brain (70450) provided on August 15, 2021.
You asked the Plan to pay for the CT scan of head or brain. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.
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 the computed tomography (CT) scan of head or brain (70450) provided on August 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 21, 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 code 14301 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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. We find that CPT code 14301 is not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement for 30.1 to 60.0 sq cm. 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 April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on January 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a
PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on January 5, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala.
You asked the Plan to pre-approve Nucala. You say that the requested Nucala is medically necessary. The Plan denied your request. The Plan says the requested Nucala is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Nucala. Our reviewer says that the requested Nucala is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of asthma and idiopathic eosinophilic. The record does not indicate that the enrollee has severe eosinophilic asthma. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nucala have not been met. Therefore, we decided that the Plan does not have to pre-approve Nucala
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine.
You asked the Plan to pre-approve the MRI. You say that you should have a course of conservative treatment first. The Plan denied your request. The Plan says this is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found a review of the records indicates that you have physical therapy in 2019, but for an unknown reason. The records do not show a neurological exam, and there are no documented plans for physical therapy. Absent any physical findings to indicate red flags to indicate an immediate MRI, this request cannot be covered without first attempting six weeks of physical therapy has not been established. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 31.
The Plan must follow Medicare rules. Medicare rules say that payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was billed with the laboratory
place of service code but the records indicate that the member's face-to-face service was rendered in a Skilled Nursing Facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the resin-based composite provided on April 20, 2021.
You asked the Plan to fully pay for the resin-based composite. You say that you want to know why the entire dental claim was not paid. The Plan denied your request. The Plan says the annual limit allowed by your dental plan has been paid.
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, you also have a maximum of $500 every year for covered dental services. The Plan paid $120 toward the resin-based composite provided on April 20, 2021, which met your maximum limit of $500. You are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to fully pay for the resin-based composite provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays rendered on December 8, 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 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 A4550 (surgical trays) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical trays rendered on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on September 1, 2021 and billed under code 72100.
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 the records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between the appealed procedure code 72100 and 72082, billed on the same claim. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifier.
In this case, this claim cannot be paid due to the omission of the required modifier. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on September 1, 2021 and billed under code 72100
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says until the pending scientific assessment of the technique has been completed and its efficacy has been established, it cannot be approved.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether implantation of the cardiac contractility modulation (CCS) system is medically necessary for the treatment of congestive heart failure, which has been deemed refractory to optimal medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, I would not consider the CCM system to be medically necessary in this 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compressor (E0651) and segmental pneumatic appliance (E0677).
You asked the Plan to pre-approve the pneumatic compressor and segmental pneumatic appliance. You say that you would like reconsideration because the requested PCD is medically necessary. The Plan denied your request. The Plan says there is no documented marked hyperkeratosis or other findings as required and there is no documented reassessment conducted to include detailed measurement prior to and at the conclusion of the trial and therapy to establish the severity of the condition.
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when the beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of the clinical findings addressed 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 the pneumatic compressor and segmental pneumatic appliance. Our reviewer says that there is no documented marked hyperkeratosis or other findings as required in LCD. Our physician reviewer found there is no documented reassessment conducted to include detailed measurement prior to and at the conclusion of the trial and therapy to establish the severity of the 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 pneumatic compressor and segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compressor (E0651) and segmental pneumatic appliance (E0677).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD) (43235) provided August 10, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you have never been charged a copayment for a colonoscopy in the past. The Plan denied your request. The Plan says no copayment was applied to the colonoscopy and the copayment was applied correctly to the EGD.
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 $175 copayment for each Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $175 copayment for the EGD. This EGD, performed in an ambulatory surgical center, falls within the Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 Esophagogastroduodenoscopy (EGD) (43235) provided August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on June 1, 2021.
You asked the Plan to pay for the testing services. You say that the treatment sought was a covered service. The Plan denied your request. The Plan says the testing does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. It appears the testing was ordered during an unsolicited outreach telephone call to the enrollee. The records show that the genetic testing would determine a risk towards cardiovascular disease. The records provided do not show that the testing was ordered for the treatment or management of a specific medical problem for the enrollee. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve stimulator placement (0424T).
You asked the Plan to pre-approve the nerve stimulator placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental and is non-covered.
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 nerve stimulator placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found only 275 patients have been studied using the device and more supportive studies are needed. 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 nerve stimulator placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve stimulator placement (0424T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology (88112, 88173), ultrasound (76536), and fine needle aspiration (10005) provided on July 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that the services rendered were necessary. The Plan denied your request. The Plan says prior authorization was not obtained prior to the services being rendered. The Plan also says that the services were not urgent or emergent in nature.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these outpatient services.
Therefore, we decided that the Plan does not have to pay for the cytopathology (88112, 88173), ultrasound (76536), and fine needle aspiration (10005) provided on July 19, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a bladder cancer screening (88120) provided on March 24, 2021.
You asked the Plan to pay for a bladder cancer screening. You say that this was billed with an appropriate diagnosis. The Plan denied your request. The Plan says this is not a covered screening service.
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, a bladder cancer screening, 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 a bladder cancer screening (88120) provided on March 24, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient mental health hospital stay provided by a participating provider on May 24, 2021, to June 2, 2021.
You asked the Plan to waive the coinsurance for an inpatient mental health hospital stay. You say that you believe you are being overcharged. The Plan denied your request. The Plan says they have partially overturned the initial decision.
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 10% coinsurance for inpatient mental health care. You have been asked to pay a 10% coinsurance of the allowed amount for an inpatient mental health hospital stay. The Plan originally asked you to pay $810. The claim has been reprocessed to reflect a new coinsurance amount of $148.40 ($1,484 (allowed amount) x 10% coinsurance = $148.40). An inpatient mental health hospital stay falls within the inpatient mental health care benefit category. 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. The total amount you are being asked to pay is $148.40.
Therefore, we decided that the Plan does not have to waive the coinsurance for an inpatient mental health hospital stay provided by a participating provider on May 24, 2021, to June 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (93979) provided March 27, 2021.
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan
denied your request. The Plan says the code billed shares a bundled relationship with another code billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93979
is a column II code to column I code 93979. 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 an ultrasound (93979) provided March 27, 2021.