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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain for the
enrollee.

You asked the Plan to pre-approve a CT scan. You say that a CT scan of the brain is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria for a CT scan are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct
criteria.

Our Medical Director reviewed the case file and the reopen request. At issue is coverage for a CT scan of the
head. The QIC Physician Reviewer determined that it would be medically appropriate to determine the
status of any possible metastases for this enrollee before proceeding with mastectomy to remove the cancer.
"Therefore, CT head is appropriate at this point." The Plan argues that a CT scan of the brain is not standard for
initial breast cancer work-up unless there is known metastatic disease with suspicious CNS symptoms. The
medical records show the enrollee had newly diagnosed infiltrating ductal cancer of the breast, ER+, PR+,
HER2-. The enrollee's examination was unremarkable. The Plan is correct. The documentation does not
support that a CT scan of the brain was medically reasonable and necessary for the enrollee in this case.
Routine brain imaging of breast cancer patients, in the absence of signs or symptoms suspicious for metastatic
disease, is not medically reasonable and 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 a CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a computed tomography (CT) scan of the brain for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for subcutaneous injection.

You asked the Plan to pre-approve the Dupixent. You say that this is medically necessary as other medications
have failed. The Plan denied your request. The Plan says this drug is administered for self-injection and is not
covered by Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent for subcutaneous
injection.

Benefits for the Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown - porcelain/ceramic for teeth #6 and 12 (D2740), core buildup, including any pins when required for teeth #2, 4, 6 and 12 (D2950), pulp cap - indirect (excluding final restoration) for teeth #5 and 13 (D3120), endodontic therapy, anterior tooth (excluding final restoration) for tooth #6 (D3310), endodontic therapy, premolar tooth (excluding final restorations) for teeth #4 and 12 (D3320), gingivectomy or gingivoplasty (D4212), pontic- porcelain/ceramic for tooth #3 (D6245), and retainer crown - porcelain/ceramic for teeth #2 and 4 (D6740).

You asked the Plan to pre-approve crown - porcelain/ceramic for teeth #6 and 12, core buildup, including any pins when required for teeth #2, 4, 6 and 12, pulp cap - indirect (excluding final restoration) for teeth #5 and 13, endodontic therapy, anterior tooth (excluding final restoration) for tooth #6, endodontic therapy, premolar tooth (excluding final restorations) for teeth #4 and 12, gingivectomy or gingivoplasty, pontic- porcelain/ceramic for tooth #3, and retainer crown - porcelain/ceramic for teeth #2 and 4. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.

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 pre-approve crown - porcelain/ceramic for teeth #6 and 12 (D2740), core buildup, including any pins when required for teeth #2, 4, 6 and 12 (D2950), pulp cap - indirect (excluding final restoration) for teeth #5 and 13 (D3120), endodontic therapy, anterior tooth (excluding final restoration) for tooth #6 (D3310), endodontic therapy, premolar tooth (excluding final restorations) for teeth #4 and 12 (D3320), gingivectomy or gingivoplasty (D4212), pontic- porcelain/ceramic for tooth #3 (D6245), and retainer crown - porcelain/ceramic for teeth #2 and 4 (D6740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided November 30, 2020.

You asked the Plan to pay for foot orthotics. You say that the orthotics were medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000) provided November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electroencephalogram (95700) provided January 25, 2021.
You asked the Plan to pay for the Electroencephalogram. You say that the services should be covered. The Plan denied your request. The Plan says the facility was out-of-network and the enrollee's deductible was not met.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to out-of-network services. The item or service you asked the Plan to pay for falls within the benefit category out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to out-of-network services.
This cost sharing is a contractual obligation that had not been met at the time the Electroencephalogram was
received on January 25, 2021. Therefore, we decided that the Plan does not have to pay for an
Electroencephalogram (95700) provided January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a corneal topography (92025) provided on April 16, 2021.
You asked the Plan to pay for a corneal topography. You say that services are medically necessary. The Plan denied your request. The Plan says denial of this service was appropriate given the clinical scenario and the guidance presented.
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 a corneal topography. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record does not indicate that the enrollee is undergoing cataract surgery. The record
indicates that the indication for the requested service is dry eye syndrome. The enrollee is being treated with
Restasis. The elements of the coverage criteria are not satisfied. The requested service is not 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 a corneal topography have not been met. Therefore, we decided that the Plan
does not have to pay for a corneal topography (92025) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network benefit exception for medical treatment to
be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an in-network benefit exception for medical treatment to be provided by an
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are
in-network providers that are able to provide these services. Therefore, coverage criteria 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 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 an in-network benefit exception for medical treatment to be provided
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the nerve destruction procedure and
Botulinum Toxin (Botox) injections you received on April 6, 2021, at an outpatient hospital facility.
You asked the Plan to waive the cost sharing for the nerve destruction procedure and Botox injections. You say
that when you had this procedure in the past, you never paid more than about $127. You say that the extra
changes were not explained to you. The Plan denied your request. The Plan says you were charged this cost
sharing correctly. The Plan confirmed that they spoke with your doctor who advised that you were notified in
June of 2020 that the doctor would only perform this procedure in an outpatient hospital facility going forward
and not in his office. The Plan says that for the procedure itself, the allowed amount ($241.44) is less than your
copayment obligation, so you are responsible for the full allowed amount. In addition, the Plan states that the
allowed amount for the Botox injections you received is $605.90, so your 20% coinsurance obligation is
$121.18.
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 $300
copayment for outpatient surgery and services at an outpatient hospital facility. Your contract also says you
must pay 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $300 copayment for the nerve destruction procedure and 20% coinsurance for
the Botox injections. The nerve destruction procedure falls within the outpatient surgery and services at an
outpatient hospital facility benefit category and the Botox injections are considered Medicare Part B drugs.
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 cost sharing for the nerve destruction procedure and Botulinum Toxin
(Botox) injections you received on April 6, 2021, at an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a sacroiliac joint injection (27096) provided on September 16, 2020.

You asked the Plan to pay for a sacroiliac joint injection. You say that this code should not be subject to billing constraints. The Plan denied your request. The Plan says the units billed exceeds MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 27096 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pay for a sacroiliac joint injection (27096) provided on September 16, 2020.
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 2, 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 70450 is 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 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from
March 1, 2021 to March 12, 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 claim was not billed with the correct type of bill code.

The Plan must follow Medicare rules. The rules say that claims must be billed with the correct Type of Bill
(TOB) code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required TOB
code for SNF services. 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 skilled nursing
facility (SNF) services rendered from March 1, 2021 to March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 22, 2021 by an out-of-network
(OON) provider.

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 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 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 office visit provided on March 22, 2021 by an
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries (66982 x 2) provided on February 24, 2021 and March 10, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $0 copayment for any surgical procedures (i.e., polyp removal) during a colorectal screening. Additionally, you pay a $300 copayment for all other outpatient services not provided in an ambulatory surgical center.

You have been asked to pay $600 ($300 copayment x 2) for the cataract surgeries provided at an outpatient hospital. 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 copayments for the cataract surgeries (66982 x 2) provided on February 24, 2021 and March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy to be provided by an out-of-
network (OON) provider.

You asked the Plan to pre-approve proton beam radiation therapy to be provided by an OON provider. You say
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that
are able to provide these services. Therefore, coverage criteria 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 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
proton beam radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 27, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 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 claim was 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 an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 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 procedure code 99291 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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
the first 30-74 minutes of critical care services spent on the enrollee. 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 critical care services rendered on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction of lesion provided on April 20, 2021.

You asked the Plan to pay for destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions (17110). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure falls under the 10-day global period.

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 find that CPT code 17110 is bundled with the CPT code 17000 provided on April 15, 2021 under the global surgery period. The medical record shows the 2 lesions were already treated. Based on this information, we decided that Medicare rules for coverage of destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions (17110) have not been met. Therefore, we decided that the Plan does not have to pay for the destruction of lesion provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E1390, E0431) provided January 25, 2021.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 20% coinsurance for Durable Medical Equipment. You have been asked to pay a $24.54 coinsurance for the oxygen equipment (20% of the allowable amount of $122.70). The oxygen equipment falls within the Durable Medical Equipment 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 coinsurance for oxygen equipment (E1390, E0431) provided January 25, 2021.