Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded 38505, 76942, and 75630 provided on June 14, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical records submitted. The Plan denied your request. The Plan says the claim has denied correctly as these services are 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 definitions of codes 38505, 76942, 75630 are:  38505 -  Biopsy or excision of lymph node(s); by needle, superficial (e.g., cervical, inguinal, axillary)  76942 -  Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation  75630 -  Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation    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 medical services. Our reviewer says that the documentation does not support payment for the services as they were billed. Our reviewer found that for CPT 38505, the operative report does not include documentation of a biopsy or excision lymph nodes to confirm this procedure has been performed. Unable to site report as this procedure is not documented. Furthermore, for  CPT 76942 the operative report does not include documentation of ultrasonic guidance for needle placement imaging supervision and interpretation. This procedure or documentation to support this procedure was unable to be cited, and this was not found in the operative report. Finally for CPT 75630, this procedure would be inclusive to CPT 37225, as a radiological supervision would be needed to perform this procedure, therefore, any addition radiological supervision and interpretation should not be reported separately in this case.  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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded 38505, 76942, and 75630 provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 22, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.      We find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical record. The services at issue are tested with a blood sample. The records show that only a urine sample was taken. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immunoassay for infectious agent antibody coded 86317 and the T cells coded 86360 provided on July 16, 2021.  You asked the Plan to pay for the immunoassay for infectious agent antibody and the T cells. 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 supported by the documentation.  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 codes 86317 and 86360 are not supported in the medical record. Specifically, medical records were not provided to support these services. The documentation does not support how the enrollee came to the servicing provider or whether the services were medically necessary. Based on this information, we decided that Medicare rules for coverage of the immunoassay for infectious agent antibody and the T cells have not been met. Therefore, we decided that the Plan does not have to pay for the immunoassay for infectious agent antibody coded 86317 and the T cells coded 86360 provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided on February 9, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0480 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. 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 11. Also, the laboratory results submitted indicate the specimen was collected on February 9, 2021, and received by the lab on February 24, 2021. Of note, the patient resides in Alabama (AL) and the billing laboratory is located in Tennessee (TN); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on May 26, 2021, by an OON provider.  You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the member does not have out-of-network benefits and the services provider is not a participating provider with the Plan.  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 an office visit (99213) provided on May 26, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the simple extractions (D7140), complete maxillary denture (D5110), removable prosthodontic procedures (D5899), and immediate mandibular denture (D5140) provided on September 16, 2021.  You asked the Plan to pay for the simple extractions, complete maxillary denture, removable prosthodontic procedures, and immediate mandibular denture. You say that you would like to appeal these services because you need insurance that is going to help you. The Plan denied your request. The Plan says these services are not covered expenses under your dental 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 simple extractions (D7140), complete maxillary denture (D5110), removable prosthodontic procedures (D5899), and immediate mandibular denture (D5140) provided on September 16, 2021.   Your complaint about being disappointed with the Plan's dental coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a targeted genomic sequence panel of 51 or greater genes (CPT code 81455 x 2) provided to the enrollee on August 26, 2021.  

You asked the Plan to pay for the laboratory services. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laboratory services. Our physician reviewer found the provided documentation did not clearly support the use of this test for this enrollee. There was insufficient explanation as to why it was being tested and how it would lead to a change in care and more importantly an improvement in overall outcome. Genetic testing does not have high quality evidence to clearly show that its use leads to improved outcomes compared to standard testing and treatment. Therefore, this request for genetic testing will be considered not medically necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for a targeted genomic sequence panel of 51 or greater genes (CPT code 81455 x 2) provided to the enrollee on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the maxillary partial denture (D5211) and simple extraction (D7140) provided on August 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the maxillary partial denture and simple extraction. You say that these services were rendered due to an emergency. The Plan denied your request. The Plan says your plan does not cover services rendered by OON providers.  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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture (D5211) and simple extraction (D7140) provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pelvic ultrasound services (76857) provided on September 9, 2021.  You asked the Plan to pay for the ultrasounds services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations.  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 76857 is a column II code to column I code 76775. 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 pelvic ultrasound services (76857) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), extraction (D7140), periapical x-ray (D0220), palliative treatment (D9110), bitewing x-rays (D0272), extraction of a partially bony impacted tooth (D7230), crown (D2752), and bone replacement graft for ridge preservation (D7953) provided from February 16, 2021, to September 30, 2021, by the out of network dentist.  You asked the Plan to pay for the dental services. You say that it was your understanding that services from this provider would be covered regardless of their network status. You also say that if you knew the service would not be covered you would not have applied for this plan. The Plan denied your request. The Plan says that dental services received out of network are not covered.  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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), extraction (D7140), periapical x-ray (D0220), palliative treatment (D9110), bitewing x-rays (D0272), extraction of a partially bony impacted tooth (D7230), crown (D2752), and bone replacement graft for ridge preservation (D7953) provided from February 16, 2021, to September 30, 2021, by the out of network dentist.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for echocardiography (93312, 93320, 93325) provided on March 16, 2021.  You asked the Plan to pay for echocardiography. You say that this is supported in the records. The Plan denied your request. The Plan says these services are not documented.  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 93312 is echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report. The definition of 93320 is doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete. The definition of 93325 is doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography).  We find that CPT codes 93312, 93320, and 93325 are not supported in the medical record. Specifically, the submitted medical records consist only of anesthesia documents and do not include sufficient documentation of echocardiography being performed. Based on this information, we decided that Medicare rules for coverage of echocardiography have not been met. Therefore, we decided that the Plan does not have to pay for echocardiography (93312, 93320, 93325) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on July 28, 2021.  You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says the correct charges have been applied.  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. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay for dental services provided by a participating provider on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0481) provided on February 10, 2021.  

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0481 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. 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 11. Also, the laboratory results submitted indicate the specimen was collected on February 10, 2021, and received by the lab on February 24, 2021. Of note, the patient resides in one state and the billing laboratory is located in a different state; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0481) provided on February 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound of the abdominal back wall (76770) provided on August 18, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare covered diagnostic radiology services received in a provider's office or freestanding facility.   You have been asked to pay a $50 copayment for the Medicare covered diagnostic radiology service provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound of the abdominal back wall (76770) provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus fee (D1999), bone replacement graft for ridge preservation (D7953), intravenous moderate sedation, first 30 minutes, (D9241) provided on November 5, 2021.  You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says the services you received are not listed as covered services.  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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the coronavirus fee (D1999), bone replacement graft for ridge preservation (D7953), intravenous moderate sedation, first 30 minutes, (D9241) provided on November 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve positron emission tomography (PET) brain imaging (78608).  You asked the Plan to pre-approve the PET scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the medical records submitted do not support the PET scan of the brain is medically necessary at this time.  The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a diagnosis of amnesia and polyneuropathy. The record provided does not indicate that the requested test is being requested to determine a differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) under specific requirements; and it is not being used in a CMS approved practical clinical trial focused on the utility of FDG PET in the diagnosis or treatment of dementing neurodegenerative diseases. The elements of the coverage criteria are not satisfied and 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) brain imaging (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the after cataract laser surgery services provided on September 7, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the after cataract laser surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 after cataract laser surgery services provided on September 7, 2021 by an out-of-network (OON) provider.