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

 We decided that the Plan does not have to pay for the spine fixation device provided from May 11, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We looked at the file and the rules. We find that CPT code 22845 was billed with code 22853. CPT code 22845 may be eligible for payment when billed with this code pair. However, the claim does not indicate the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the spine fixation device provided from May 11, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab services (G0483) provided June 7, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the records do not support the billed services.

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 G0483 is Drug Testing, 22 or more drug classes. 

We find that CPT code G0483 is supported in the medical record. Specifically, the provided records support that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the lab services have been met. Therefore, we decided that the Plan has to pay for lab services (G0483) provided June 7, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 70450 provided on July 14, 2021.  You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 for the x-ray services 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 x-ray services coded 70450 provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided June 21, 2021.  You asked the Plan to pay for the limited oral exam and the first and additional periapical x-rays. You say that you haven't had any dental cleanings this year and feel you are entitled to coverage. The Plan denied your request. The Plan says these services are not covered by your plan.  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 limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (CPT code(s) 92004, 92285, 
92342, 92250) provided to the enrollee on July 20, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network ophthalmological services. You say that the provider has no 
prior knowledge of which patients they will be required to see. The Plan denied your request. The Plan says 
this provider is out-of-network, the services were not referred by a network provider, and the services were not 
urgent or emergent, nor were they approved in advance. 
 
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. 
Additionally, code 92134 is a column II procedure to the column I procedure 92133 which was processed on a 
different claim. The Centers for Medicare & Medicaid Services (CMS) Correct Coding Initiative (CCI) 
Procedure-to-Procedure (PTP) code pair edits has identified column I procedure codes and their associated 
column II procedure codes based on the principles of correct coding; therefore, CPT code would not have paid 
also. Therefore, we decided that the Plan does not have to pay for the ophthalmological services (CPT code(s) 
92004, 92285, 92342, 92250) provided to the enrollee on July 20, 2021, by an out-of-network provider.
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 have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of additional physical therapy services have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, nor are the specialized skill, knowledge, and judgment of a qualified therapist required to establish, design, and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten (10) additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the number of visits is excessive for this condition. There is no change in the enrollee's condition in the three visit notes provided. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. There is no documentation provided to support that the requested services are part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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 pay for the services provided by an out-of-network provider on February 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services (99491) rendered by 
the out-of-network (OON) provider on June 30, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chronic care management services (99491) rendered by the out-of-network 
(OON) provider on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins (93971) provided on April 
27, 2021. 
 
You asked the Plan to pay for a duplex scan of extremity veins. You say that this is supported in the records. 
The Plan denied your request. The Plan says this is not separately payable. 
 
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 93971 is a column II code to column I code 93970, which was previously billed and paid for this date of service. 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 a 
duplex scan of extremity veins (93971) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit you had with an anesthesiologist 
on July 6, 2021. 
 
You asked the Plan to waive the copayment for the anesthesiology visit. You say that you do not think it is fair 
to be charged this copayment.  You said that you were in the hospital and just saw this provider in the operating 
room. The Plan denied your request. The Plan says you were charged this copayment 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 $35 
copayment for specialist visits in an outpatient hospital setting.  
 
You have been asked to pay a $35 copayment for the anesthesiology visit. The anesthesiology visit falls within 
the specialist visits in an outpatient hospital setting 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 visit you had with an anesthesiologist on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of subcutaneous tissue (11042, 11045) 
provided on April 12, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a debridement of subcutaneous tissue. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care 
have not been met. 
 
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 a debridement of subcutaneous tissue (11042, 
11045) provided on April 12, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97530) provided on March 9, 2021 to 
March 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the provider is not eligible for Medicare payment and is not in-
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 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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for chiropractic services (97530) provided on March 9, 2021 to March 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by the out-of-
network (OON) provider on July 13, 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 psychotherapy service (90837) rendered by the out-of-network (OON) provider on 
July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D assay testing provided to you on June 8, 2021. 
 
You asked the Plan to pay for the vitamin D testing. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that vitamin D assay testing is covered for the 
indications established in the applicable LCD.  
 
We looked at the file and Medicare rules. The vitamin D testing was provided for a diagnosis of elevated blood 
pressure (R030) and hyperlipidemia (E785). These are not covered indications per LCD L34051. Based on this 
information, we decided that Medicare rules for coverage of the vitamin D testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the vitamin D assay testing provided to you on 
June 8, 2021.