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

We decided that the Plan does not have to pay for the intraoperative neuromonitoring provided on April 5,
2021.
You asked the Plan to pay for the intraoperative neuromonitoring. You say that the service was ordered by the
in-network surgeon as a surgical requirement and was provided at an in-network facility. You say that the
services were billed in accordance with the terms of the policy and are requesting reprocessing of the claim.
The Plan denied your request. The Plan says the claim was processed correctly.
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 the intraoperative neuromonitoring is not supported in the medical record. Specifically, it is not
appropriate to append modifier 78 to services that do not have a global period of 0010 or 0090. CPT codes
95938, 95939, 95955, 95937, and G0453 do not have a global period. There is a more appropriate modifier for
the services billed. Based on this information, we decided that Medicare rules for coverage of the intraoperative
neuromonitoring have not been met. Therefore, we decided that the Plan does not have to pay for the
intraoperative neuromonitoring provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home physician visit (house call) provided on June 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician visit. You say that you are appealing with supporting records. 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 home physician visit (house call) provided on June 8, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided May 4, 2021.
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says there is no documented contact with the attending/primary care physician. There is no referring physician listed on the claim.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. The submitted claim does not include a referring provider for the services at issue. The records do not show that the enrollee's primary care physician was contacted. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided May 4, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76770 provided on June 4, 2021.

You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 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 76770 for the ultrasound has a bundled relationship with code 93975 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 ultrasound coded 76770 provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (88112) provided on December 29, 2020.
You asked the Plan to pay for cytopathology services. You say that this should be covered. The Plan denied your request. The Plan says this 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. 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 code 88112 is not supported in the medical record. Specifically, no records documenting this service have been submitted. Based on this information, we decided that Medicare rules for coverage of cytopathology services have not been met. Therefore, we decided that the Plan does not have to pay for cytopathology services (88112) provided on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound supplies provided on April 22,
2021.
You asked the Plan to waive the coinsurance for wound supplies. You say that you were advised by a
representative of the Plan not to pay the bill at issue. The Plan denied your request. The Plan says the correct
copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare-covered durable medical equipment.
You have been asked to pay $26.38, or 20% of the Medicare-allowed charge of $131.91, for wound supplies.
Wound supplies fall within the "Durable medical equipment (DME) and related supplies" 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 wound supplies provided on April 22, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities
from a representative of the Plan 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity weakness and suicidal thoughts. Medical problems are stable.
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair provided on June 18, 2021.
You asked the Plan to pay for a shower chair. You say that you are disabled, and this claim is based on medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral periapical radiographic images (D0220, D0230 x2), a panoramic radiographic image (D0330), and a teeth cleaning (D1110) provided on June 30, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, intraoral periapical radiographic images, a panoramic radiographic image, and a teeth cleaning. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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 a comprehensive oral evaluation, intraoral periapical radiographic images, a panoramic radiographic image, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), intraoral periapical radiographic images (D0220, D0230 x2), a panoramic radiographic image (D0330), and a teeth cleaning (D1110) provided on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.

You asked the Plan to pre-approve the requested device. You say that the enrollee has failed more than 6
months of conservative approaches to treatment. The Plan denied your request. The Plan says experimental and
investigational procedures are not covered by Medicare.

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 requested device. Our physician
reviewer found that the interspinous process stabilization devices remain experimental. More research is
needed to show safety and efficacy of the devices. Therefore, the requested service is not medically reasonable
or necessary at this time.

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 requested device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous stabilization device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crown (D6750) for a fixed bridge.
You asked the Plan to pre-approve the pontic (D6240) and retainer crown (D6750) for a fixed bridge. You say that you require this bridge, this is not a cosmetic request. The Plan denied your request. The Plan says the requested three-unit posterior fixed bridge is beyond the scope of benefit coverage.
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 covers the pontic (D6240) and retainer crown (D6750) for a fixed bridge when the services are medically necessary and reasonable.
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 pontic (D6240) and retainer crown (D6750) for a fixed bridge. Our reviewer says that the requested bridge is not medically necessary. Our physician reviewer found that the missing tooth is in the posterior region of the mouth, and there has been not been any documentation provided that indicates a physical or neurologic disorder that would prevent placement of a removable prosthesis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic (D6240) and retainer crown (D6750) for a fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crown (D6750) for a fixed bridge.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee was admitted for total knee replacement. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).

You asked the Plan to provide coverage for additional transportation trips. You say that you are requesting additional trips for doctor visits. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 60 one-way trips per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is covered when specific criteria are 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 pre-approve these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee has lumbar spinal stenosis and foot drop and a current standard wheelchair. The records do not show that she requires individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles that cannot be accommodated by a standard wheelchair. The ultra lightweight wheelchair is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and phone
holder (K0108).

You asked the Plan to pre-approve the power seat elevation system and phone holder. You say that the items
are medically necessary. The Plan denied your request. The Plan says the items are not primarily medical in
nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and phone holder
(K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt and recline seating system for a power wheelchair.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says you have used a manual wheelchair for thirteen years without any skin breakdown on seating surfaces.
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 you are able to perform a functional weight shift and are able to transfer independently from wheelchair to bed. You do not have increased tone or spasticity. 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 a power tilt and recline seating system for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee can be transferred to LTACH for continuation of care that requires ongoing acute care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the health care setting being offered by the Plan. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray of the chest coded as 71046 provided on June 30, 2021.
You asked the Plan to pay for the X-ray of the chest. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier was not billed with this claim.
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 71046 has a bundled relationship with code 32555and 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 X-ray of the chest coded as 71046 provided on June 30, 2021.