Persius/hicric huggingface dataset:
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 device 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 the indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multiple level disease including moderate spinal stenosis at L3-L4 and severe spinal stenosis at L4-L5, the levels requested for treatment. The record does not document that the enrollee is not indicated for operative treatment at more than two levels. The record does not indicate that the enrollee has pain relief in flexion or evidence of the non-operative treatment. 

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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 8, 2021, billed with code 99285.
You asked the Plan to pay for the ED services. You say that this visit should be payable. The Plan denied your request. The Plan says code 99291 was paid to this provider for the date of service. 99285 is a Column 2 code and cannot be separately paid, even with a modifier.
The Plan must follow Medicare rules. Medicare rules say that ED services are not payable on the same date to a physician who provides critical care services.
The file shows that critical care services were paid to this physician for the date of service at issue. ED services
cannot also be paid on the same date. Therefore, we decided that the Plan does not have to pay for the
emergency department (ED) services provided on April 8, 2021, billed with code 99285.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the magnetic resonance imaging (MRI) of the brain, MRI of the spine, and MRI of the upper extremities you had on February 19, 2021.
You asked the Plan to waive the copayments for the MRIs. You say that you were told there would only be one copayment for these services. The Plan denied your request. The Plan says you were charged three copayments correctly. The Plan says that although you had three different MRIs, you are only being charged two copayments. The Plan has decided to not correct this error since it is in your favor.
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 $75 copayment for MRIs.
You have been asked to pay a $75 copayment for two of the MRIs. This copayment applies per service, not per day. 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 magnetic resonance imaging (MRI) of the brain, MRI of the spine, and MRI of the upper extremities you had on February 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services provided on April 2, 2021 to April 29, 2021 by an out-of-network provider.
You asked the Plan to pay for the therapy services (97110, 97112, 92507, 92523). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not obtain prior authorization as required.
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 therapy services provided on April 2, 2021 to April 29, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a venipuncture (blood draw) provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for venipuncture. You say that this was medically necessary as to not compromise the enrollee's health and well-being. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 venipuncture (blood draw) provided on April 1, 2021 by an out-of-network (OON) provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 20,
2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for medical services provided to the enrollee on January 20,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography provided on May 12, 2021.
You asked the Plan to pay for computed tomography, head or brain; without contrast material (70450). You say that the enrollee had multiple exams on this date so the Plan should pay this claim. The Plan denied your request. The Plan says procedures that represent overlapping services are considered mutually exclusive.
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 computed tomography, head or brain; without contrast material (70450) has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive problem-focused oral evaluation (D0160) provided on June 8, 2021.
You asked the Plan to pay for the extensive oral evaluation. You say that this service was necessary, and you needed to see this dentist because they specialize in caring for your condition. The Plan denied your request. The Plan says this type of oral exam is not covered by your dental benefit. In addition, services obtained from a provider who does not participate in the Plan's dental vendor 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. The Plan can cover periodic oral evaluations and limited/comprehensive exams. Services obtained outside the Plan's dental vendor network are not covered.
Though the Plan offers a dental benefit in excess of Medicare coverage, the type of oral exam requested is not covered under this benefit. The exam was also performed by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the detailed and extensive problem-focused oral evaluation (D0160) provided on June 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 16, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the dosage is not adjusted based on obtained readings.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are only on once-daily insulin. The elements of the coverage criteria are not satisfied. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 18,
2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for medical services provided to the enrollee on January 18,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve respiratory equipment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve respiratory equipment. You say that this equipment is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide for the enrollee's medical needs.
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 respiratory equipment 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 targeted genomic sequence analysis panel testing (code 81455) provided on March 14, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is medically necessary and was ordered by the treating physician to determine the course of treatment for this enrollee. The Plan denied your request. The Plan says this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis code 81455 will be automatically denied as not medically necessary. We looked at the file and Medicare rules. This test code is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (code 81455) provided on March 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 88184, 88185, 88189, 88368, 88377, 81263, and G0452 provided on March 24, 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 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 88184, 88185, 88189, 88368, 88377, 81263, and G0452 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11.
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 the laboratory services coded 88184, 88185, 88189, 88368, 88377, 81263, and G0452 provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for out-of-network services (annual wellness
visit and venipuncture) received on April 8, 2021.
You asked the Plan to waive the coinsurance for the services. You say that you were told that this provider was
in-network. The Plan denied your request. The Plan says the cost-sharing was 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 50%
coinsurance for out-of-network office visits and venipuncture.
You have been asked to pay 50% coinsurance for the services. The services fall within the out-of-network
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 coinsurance for out-of-network services (annual wellness visit
and venipuncture) received on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of diagnostic mammography services provided on April 15, 2021, billed with codes 77065-26-RT and 77065-26-LT.
You asked the Plan to pay for the mammogram interpretation as billed. You say that this should be paid. The Plan denied your request. The Plan says this code cannot be reported twice or with laterality modifiers.
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. The rules also say that providers must report services using the correct code. In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. The CPT definition of this code is unilateral. As such, it is not appropriate to use for bilateral procedures. There is a code (77066) which is used for this purpose. Based on this information, we decided that Medicare rules for coverage of the mammogram interpretation as billed have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of diagnostic mammography services provided on April 15, 2021, billed with codes 77065-26-RT and 77065-26-LT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), and problem focused limited oral evaluation (D0140), or pay more for the endodontic therapy (D3320) provided on June 8, 2021 by an OON provider.
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral evaluation, and to pay more for the endodontic therapy. You say that you had an appointment scheduled with this treating provider, but the Plan recommended you should see another provider. You also say that you kept the appointment with this treating provider because you were able to be seen much sooner. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not a covered benefit, and your benefits for the problem focused limited oral evaluation have been exhausted. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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 cone beam CT capture and interpretation is not among those covered under this benefit. The contract says that periodic oral exam and emergency diagnostic exam share a frequency limitation of two procedure codes per calendar year. The record shows that you received an emergency diagnostic exam on April 1, 2021, and a periodic oral exam on April 20, 2021 and your periodic oral exam and emergency diagnostic exam benefits have been exhausted. The contract also says that you are responsible for a 75% coinsurance plus the difference between the billed amount and allowed amount when a root canal is rendered OON. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), and problem focused limited oral evaluation (D0140), or pay more for the endodontic therapy (D3320) provided on June 8, 2021 by an OON provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation coded as 90687,
90868 and 90869.
You asked the Plan to pre-approve transcranial magnetic stimulation. You say that you are treating the enrollee
and would like to appeal the denial. Risks of not being able to follow your recommended treatment plan
include worsened symptoms, psychiatric hospitalization and suicide. The Plan denied your request. The Plan
says the records do not support that this care is needed to treat your condition and does not meet the coverage
criteria for transcranial magnetic stimulation.
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 transcranial magnetic stimulation. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based on the information provided, this enrollee does not meet the clinical
criteria for the use of TMS therapy utilizing LCD (L33398). Documentation presented does not show the
enrollee to be prescribed within the medication guidelines and no documented standardized rating scales PHQ
9 and GAD 7. This enrollee does not meet the criteria as outlined by the LCD requirement for Transcranial
Magnetic Stimulation (TMS) and is therefore not considered 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 transcranial magnetic stimulation have not been met. Therefore, we decided that
the Plan does not have to pre-approve transcranial magnetic stimulation coded as 90687, 90868 and 90869.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the hand you had at an outpatient hospital facility on April 30, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you were not told that there would be a copayment for this service. You said that you were unable to get this x-ray done at your primary care physician's office due to the Coronavirus pandemic. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this x-ray ($75.29) is less than your copayment obligation, you are responsible for the full allowed amount.
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 $100 copayment for basic radiological services at an outpatient hospital. You have been asked to pay a $100 copayment for the x-ray. This copayment applies regardless of the reason why you went to the outpatient hospital facility. 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 x-ray of the hand you had at an outpatient hospital facility on April 30, 2021.