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

 We decided that the Plan does not have to pay for surgical assistant services (10140) provided July 30, 2021.  You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says this procedure is not eligible for payment for surgical assistants.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 10140. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services (10140) provided July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the oxygen equipment to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the oxygen equipment. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.    The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the oxygen equipment 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 angiography services (75736 and 75774) provided on August 16, 2021.  You asked the Plan to pay for the angiography services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between 75736, 75774 and 37242.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the angiography services. Our reviewer says that CPT code 75736 does not meet criteria for billing or reimbursement consideration. 75736 26 XU x2 has a bundled relationship with 37242, however, an appropriate modifier is allowed to unbundle the services providing the medical records support the use of an appropriate modifier.  In this case, the medical records provided do not include sufficient documentation to support the use of the XU modifier to identify 75736 26 XU x2  as a distinct, separate service, therefore, no additional reimbursement is allowed. Our reviewer found CPT code 75774 does not meet criteria for billing or reimbursement consideration. 75774  26 XU x3 has a bundled relationship with 37242, however, an appropriate modifier is allowed to unbundle the services providing the medical records support the use of an appropriate modifier.  In this case, the medical records provided do not include sufficient documentation to support the use of the XU modifier to identify 75774 26 XU x3 as a distinct, separate service, therefore, no additional reimbursement is allowed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the angiography services have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services (75736 and 75774) provided on August 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation (76536) provided August 26, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you feel your diagnostic test should be covered with a $25 copayment. The Plan denied your request. The Plan says the copayment has been applied correctly.   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 $150 copayment for each Medicare-covered radiological diagnostic service.  You have been asked to pay a $106 copayment for the ultrasound. The ultrasound falls within the Outpatient diagnostic tests and therapeutic services 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 ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation (76536) provided August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 2, 2021 and April 30, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable as billed.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 2, 2021 and April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted with hypoxic respiratory failure due to coronavirus pneumonia. The record indicates that the enrollee continues to require high flow oxygen and is not clinically stable. The record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.    

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 the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.  

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and success of this treatment.  

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 requested services. Our physician reviewer found that the enrollee has chronic bilateral knee pain. She is doing a home exercise program, tried wearing a brace as well as applying ice/heat. She has trialed Tylenol, Celebrex, Tramadol, and Hydrocodone. She has had 2 diagnostic sets of left genicular nerve blocks. The first gave her 50% pain relief. The second gave her 80% pain relief. The request is for radiofrequency ablation of the left genicular nerves. This is considered an experimental/investigational procedure at this point. Therefore, the request is deemed not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the FoundationOne testing provided on August 23, 2021.  You asked the Plan to pay for the testing services. You say that the test is medically necessary to assist in treatment decisions. The Plan denied your request. The Plan says that service providers should use 1 unit of code 81479.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and the rules. We find that CPT code 0037U is supported. The case file includes a notification from the Centers for Medicare and Medicaid Services that identifies code 0037U as the billable code for the testing service, effective as of 2018. The Healthcare Common Procedure Coding System (HCPCS) and CPT Codebook Appendix for Multianalyte Assays with Algorithmic Analyses and Proprietary Laboratory Analyses codes also confirms code 0037U is to be used for the testing at issue in this case. CPT code 81479 is used when there is no CPT code to accurately describe the procedure performed. Based on this information, we decided that Medicare rules for coverage of the testing services have been met. Therefore, we decided that the Plan has to pay for the FoundationOne testing provided on August 23, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on September 8, 2021.  

You asked the Plan to pay for the intraoral periapical x-rays. You say that you should have been asked about these procedures. You also say that this needs to be paid. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only types of x-rays that are covered under your plan are bitewing x-rays and full mouth or panoramic x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the peri-implant capsulectomy (19371) provided on June 11, 2021.  

You asked the Plan to pay for the peri-implant capsulectomy (19371). You say that CPT code 19371 was independent and distinct and there are edits that can be overridden using appropriate modifiers. You say that the operative notes detail the services performed and the claim should be reprocessed accordingly. The Plan denied your request. The Plan says procedure code 19371-50-59 is not supported by the medical records submitted.   

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 19371 is peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents.  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the peri-implant capsulectomy (19371). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that a peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents was performed on June 11, 2021, as a distinct and separate procedure, therefore this procedure cannot be verified.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the peri-implant capsulectomy (19371) have not been met. Therefore, we decided that the Plan does not have to pay for the peri-implant capsulectomy (19371) provided on June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 

 The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted with sepsis and acute kidney injury in the setting of lupus.    

The record indicates that the enrollee is improving but still requires intravenous antibiotics and oxygen supplementation. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telehealth services received on August 31, 2021, by an OON provider.  

You asked the Plan to pay for the telehealth services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  

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 telehealth services received on August 31, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the outpatient hospital services provided from April 16, 2021, to April 21, 2021.  

You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment for outpatient hospital services citing Medicare payment guidelines for inpatient hospital services. The file shows that the services provided were outpatient/observation care in an outpatient hospital setting. The claim submitted for payment by the outpatient hospital facility was billed as outpatient hospital services correctly. The Plan has not provided any supporting Medicare guidelines as evidence that the outpatient hospital services do not meet Medicare payment criteria. Therefore, we decided that the Plan has to pay for the outpatient hospital services provided from April 16, 2021, to April 21, 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 waive the copayment for the vision exam received on September 2, 2021.  

You asked the Plan to waive the copayment for the vision exam. You say that you feel this should be routine and a $0 copayment The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.  

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 $25 copayment for vision care.   

While you feel this visit should fall within the routine vision exam, the documentation shows that this visit went above and beyond what is covered during a routine vision exam. You have been asked to pay a $25 copayment for the vision exam. The vision exam falls within the vision 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. Therefore, we decided that the Plan does not have to waive the copayment for the vision exam received on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided November 5, 2021.  

You asked the Plan to pay for the tooth extractions. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided November 5, 2021.