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

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture (D0383) provided on August 4, 2021.
You asked the Plan to pay for the dental service. You say that you pay for the dental rider which includes oral exams and also pictures (images) of your teeth. You say that your dentist took images of your teeth. You also say that you are not appealing the implant because you know it is not covered. The Plan denied your request. The Plan says the cone beam CT image is not listed as a covered service.
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 image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture (D0383) provided on August 4, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (32555) provided on June 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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.
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 services. Our reviewer says that the use of code 32555 is
not supported by the records provided. Our reviewer found that the documentation for services provided does
not support that two separate services were performed on same date. Therefore, the documentation supports
duplicate billing.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (32555) provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on March 7, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the unlisted molecular pathology procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on March 7, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 10, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical radiographic images (x-rays) (D0220 and D0230), and bitewing radiographic images (D0274), provided on July 26, 2021.

You asked the Plan to pay for the periapical and bitewing x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exhausted your Plan benefit for this service.

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 periapical radiographic images (x-rays) (D0220 and D0230), and bitewing radiographic images (D0274), provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections.
You asked the Plan to pre-approve epidural steroid injections. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 epidural steroid injections. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has left sided neck pain that radiates to the right arm. The LCD
notes that an epidural steroid injection can be repeated in 3 months if there is persistent reduction in symptoms
of at least 50%. A maximum of four are allowed in a rolling 12-month period, and continuation for more than
12 months is generally not considered medically needed. In this case, it has not been three months since the
first injection on September 28, 2021. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing provided on June 28, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed have not met the associated frequency relationship criteria.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan states that this drug testing has not met the associated frequency relationship criteria. However, the documentation does not support any previous drug testing rendered. This means the Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the drug testing provided on June 28, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided February 24, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the billed amount of this service exceeds the allowed frequency.
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 80307 is not supported in the medical record. Specifically, per Local Coverage
Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) this service is
limited to 12 tests per year. Based on this information, we decided that Medicare rules for coverage of the lab
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307)
provided February 24, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the guided tissue regeneration (D4266 x 3), and pedicle soft tissue graft procedure (D4270 x 3) provided on May 25, 2021.
You asked the Plan to reimburse you for the guided tissue regeneration and soft tissue graft procedure. You say that your dentist advised that you needed this dental work. You say that they advised if it was not completed and left untreated, it would lead to health complications. You also say that these services were medically necessary. The Plan denied your request. The Plan says the services you received are routine dental in nature. The Plan says that routine dental services are not covered under your medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the guided tissue regeneration (D4266 x 3), and pedicle soft tissue graft procedure (D4270 x 3) provided on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70491 provided on June 12, 2021.
You asked the Plan to pay for the computed tomography (CT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70491 for the computed tomography (CT) is a column II code to column I code 70498. 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 computed tomography (CT) coded 70491 provided on June 12, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (80307) provided on January 6, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says that this does not meet the associated frequency relationship criteria.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say that it is not appropriate to report more than twelve (12) presumptive urine drug testing (UDT) (code 80305, 80306, or 80307) services per calendar year. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan states that the testing at issue was denied due to frequency, the Plan has not provided any documentation showing when the enrollee previously received this testing. Therefore, we decided that the Plan has to pay for drug testing (80307) provided on January 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on July 7, 2021 to July 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that routine urine drug testing is necessary to monitor the use of these prescriptions as a part of the Prescription Drug Monitoring Program. The Plan denied your request. The Plan says you are not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in an in-network facility, the services were not urgent or emergent, and the services were not approved in advanced.
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 Plan contract also says that you must obtain authorization from the plan prior to seeking care from an outof-
network provider.
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 drug testing (G0480) provided on July 7, 2021 to
July 21, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (80307) provided on April 29, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says that the frequency relationship criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say that it is not appropriate to report more than twelve (12) presumptive urine drug testing (UDT) (code 80305, 80306, or 80307) services per calendar year. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan states that the testing at issue was denied due to frequency, the Plan has not provided any documentation showing when the enrollee previously received this testing. Therefore, we decided that the Plan has to pay for drug testing (80307) provided on April 29, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81450) provided June 9, 2021.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this test is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic tests are covered if the test has satisfactorily completed a technical assessment by MolDX for the stated indications of the test.
We looked at the file and Medicare rules. The test has not completed a technical assessment for the state indications of the test and therefore is non-covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81450) provided June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS).

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no good proof that this device helps with muscle tightness of weakness.

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 stimulator. Our reviewer says that the requested stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found you have muscle tightness and weakness. There is no data to suggest that the TENS unit is effective for this. 

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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the OON provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested services.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office
visits to be rendered by the OON provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing provided on June 2, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed exceed the frequency limit.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan states that this drug testing has not met the associated frequency relationship criteria. However, the documentation does not support any previous drug testing rendered. This means the Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the drug testing provided on June 2, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy provided on January 2, 2020.
You asked the Plan to pay for the electric stimulation therapy. You say that the incorrect provider was chosen when the claim was processed resulting in out-of-network processing. You say that you are a contracted provider, and the claim should be processed at the in-network level. 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 electric stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy provided on January 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve a genicular nerve block. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 a genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic knee pain. The enrollee is experiencing worsening pain and has noted knee pain also worsens with flexion/extension. The pain is reported to impede on activities of daily living performance and quality of life. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. Therefore, the enrollee does not meet criteria for the requested services. 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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.