Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220) provided on May 11, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image. You say that the provider is listed as in-network. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every calendar year.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service on May 3, 2021.
Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220) provided on May 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition solutions (B4197) and parenteral nutrition administration kits (B4224) provided from November 28, 2020, to December 3, 2020.
You asked the Plan to pay for the parenteral nutrition solutions and parenteral nutrition administration kits. You say that the services provided to the enrollee were medically necessary. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 the parenteral nutrition solutions (B4197) and parenteral nutrition administration kits (B4224) provided from November 28, 2020, to December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for custom fabricated abutments (D6057 x2), abutment supported crowns (D6058 x2), and pontic (D6245) provided on May 7, 2021.
You asked the Plan to pay for custom fabricated abutments, abutment supported crowns, and pontic. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for custom fabricated abutments (D6057 x2), abutment supported crowns (D6058 x2), and pontic (D6245) provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a segmental pneumatic compression device
(E0652) with full leg sleeves (E0667) with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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
a referral for a segmental pneumatic compression device (E0652) with full leg sleeves (E0667) with an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure does not improve outcomes compared to standard treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of sacroiliac joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry testing services provided on
February 24, 2021.
You asked the Plan to pay for the testing services. 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.
In this case, the CPT Code Manual definition of code 88341 is immunohistochemistry or
immunocytochemistry, per specimen; each additional single antibody stain procedure (list separately in
addition to code for primary procedure).
The file shows that CPT code 88341 was billed with code 88360. We find that code 88341 may be eligible for
payment if an appropriate modifier appended. The provided claim does not show that the code at issue was
billed with a modifier suitable for separate payment. Based on this information, we decided that Medicare rules
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay
for the immunohistochemistry testing services provided on February 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy provided on January 29, 2021.
You asked the Plan to pay for the electrical stimulation therapy. You say that you are a contracted provider and do not require authorization in order to have claims processed at the in-network level. You say that the claim should be reprocessed. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes.
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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended).
We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (87150, 87481, 87798, 87801) provided on April 28, 2021.
You asked the Plan to pay for laboratory testing. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT codes 87150, 87481, 87798, and 87801 are not supported in the medical record. Specifically, the submitted records do not include documentation of these tests being performed or the results. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (87150, 87481, 87798, 87801) provided on April 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy provided on February 2, 2021.
You asked the Plan to pay for the electrical stimulation therapy. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes.
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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from January 26, 2021, through March 2, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from January 26, 2021, through March 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transports (A0428) provided from October 22, 2020, to December 22, 2020.
You asked the Plan to waive the copayment for the non-emergency ambulance transports. You say that you called the Plan and were told the contract was updated by someone during the pandemic and you were advised you would not have to pay for transportation from the rehabilitation facility to doctors' appointments. You also say that you offered to have your daughter transport you but were told that you had to use a chair van. The Plan denied your request. The Plan says the copayment amounts that you are being charged are correct. The Plan also says that the transportation services were not related to the Coronavirus, and therefore the temporary policy would not apply.
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 $90 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $90 copayment for Medicare-covered ambulance services per day for the non-emergency ambulance transports. Non-emergency ambulance transports fall within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the non-emergency ambulance transports (A0428) provided from October 22, 2020, to December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Theraskin.
You asked the Plan to pre-approve Theraskin. You say that the requested Theraskin is medically necessary. The Plan denied your request. The Plan says the requested Theraskin is not medically necessary.
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 Theraskin. Our reviewer says that the requested Theraskin is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a wound on the lower leg that measures 18 by 13 cm, improved from a week earlier with maximum dimension of 24 cm. The record indicates that the wound has good granulation tissues. The record does not indicate that standard wound therapies would not be effective for the enrollee. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Theraskin have not been met. Therefore, we decided that the Plan does not have to pre-approve Theraskin.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for the x-ray of the spine and Magnetic Resonance Imaging (MRI) of the spine (72100 and 72148) provided on May 6, 2021.
You asked the Plan to hold you harmless for the x-ray of the spine and MRI. You say that you would like reconsideration because you should not have any liability and the Plan is responsible for obligating the provider to take the Medicare contractual write off. The Plan denied your request. The Plan says that they are not liable for paying your cost share or obligating the provider to take our Plan's contractual write off versus the Primary payer's contractual write off.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The services at issue were billed by a contract provider. The Plan is responsible for ensuring that the provider accepts this payment in full and holds you harmless for the remainder.
The Plan is responsible for ensuring that this provider takes the contractual write-off. Therefore, we decided that the Plan has to hold you harmless for the x-ray of the spine and Magnetic Resonance Imaging (MRI) of the spine (72100 and 72148) provided on May 6, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet LCD criteria for the requested radiofrequency ablation procedure.
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 radiofrequency ablation. Our reviewer says that the enrollee does not meet LCD criteria for the requested radiofrequency ablation procedure. Our physician reviewer found there is no documentation of the lumbar levels to be treated and no documentation of any prior medial branch block (MBB)/facet joint injections performed to the lumbar region. There is no documentation to support that the enrollee has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and activities of daily living; OR after the enrollee has had at least one (1) medically reasonable and necessary therapeutic injection that provided at least 50% pain relief for at least three (3) months. The review has determined that the enrollee does not meet the above LCD criteria for the requested radiofrequency ablation procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Synvisc.
You asked the Plan to pre-approve Synvisc. You say that you need this injection right away because you are in a lot of pain. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Durolane, Euflexxa, Supartz, or Gelsyn-3 before it will approve Synvisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Synvisc. Our physician reviewer found you have not tried the Plan's preferred drugs of Durolane, Euflexxa, Supartz, or Gelsyn-3. The record does not show that these drugs would likely be less effective and/or have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Synvisc.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation of the right greater saphenous vein.
You asked the Plan to pre-approve the endovenous ablation. You say that it is felt that this procedure is medically necessary. The Plan denied your request. The Plan says this treatment is not supported in a vein with thrombosis.
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 endovenous ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is status post bilateral vein ligation or stripping. There is a plan for right greater saphenous vein ablation, although there is thrombus noted in the greater saphenous vein mid-thigh, no reflux in the greater saphenous vein above-knee, and the vein was not present at the mid-calf.
Most importantly, based on the documentation, it is not clear if the provider is aware of these findings as they are not addressed in the assessment and plan. Furthermore, in the appeal letter there is no mention of the crux of the denial which is the greater saphenous vein thrombus. As it is unclear if there is a plan to address this thrombus and areas of greater saphenous vein non-presence and areas of non-reflux, the requested procedure cannot be considered 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 the endovenous ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation of the right greater saphenous vein.