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

We decided that the Plan does not have to pre-approve a lung biopsy (32608) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the lung biopsy. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers that can provide the procedure at issue.
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 a lung biopsy (32608) to be provided by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you are in need of physical therapy, occupational therapy, and speech therapy. The Plan denied your request. The Plan says this request is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rebase of upper false teeth (D5710) and rebase of lower false teeth (D5711).
You asked the Plan to pre-approve the dental services. You say that you feel that you need these services soon. You also say that you do not want to make an appointment until you know that the services will be approved. The Plan denied your request. The Plan says denture rebase is covered once per denture, every 3 calendar years. The Plan also says that the frequency limit has been reached.
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 and denture rebase is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for denture rebases that you received on January 25, 2021. Therefore, we decided that the Plan does not have to pre-approve rebase of upper false teeth (D5710) and rebase of lower false teeth (D5711).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).

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. The rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

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 services are not medically necessary. Our physician reviewer found that you have already had two RFA sessions within a 12-month period for the same lumbar area. The prior sessions were performed on January 13, 2021 and July 30, 2021 at the right L3 to L4 and L4 to L5 region. A third session is not covered. 

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 repeat radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249).

You asked the Plan to pre-approve the dental service. You say that you had a temporary crown placed. You say that it broke a few days later. You say that you switched to a new dentist to have this taken care of. You also say that the service is medically necessary. The Plan denied your request. The Plan says clinical crown lengthening 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 requested clinical crown lengthening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve clinical crown lengthening (D4249).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that this is a proven treatment which is medically necessary. The Plan denied your request. The Plan says there is not sufficient evidence in the peer-reviewed literature to support that this service is medically reasonable and 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 the Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer remains experimental at this time. More research is needed to determine safety and efficacy. 

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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
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 requested admission to an IRF does not meet
criteria.
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 enrollee continues to have a need for skilled therapy with ongoing safety
concerns and a potential for functional improvement however, the documentation doesn't support that he would
meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the
supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. The enrollee
can receive services at a lower level of care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical removal of an erupted tooth (D7210) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a surgical removal of an erupted tooth. You say that you would like to get your tooth pulled because it causes you to have a lot of pain at night. The Plan denied your request. The Plan says the Plan provides coverage for dental services when they are performed by a participating general dentist.

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 a surgical removal of an erupted tooth (D7210) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral-periapical first radiographic image (D0220) provided by a participating provider on July 30, 2021.
You asked the Plan to pay for an intraoral-periapical first radiographic image. You say that these were preventative x-rays and should be covered. The Plan denied your request. The Plan says D0220 is not a covered benefit.
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 an intraoral-periapical first radiographic image (D0220) provided by a participating provider on July 30, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64494) provided on July 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has been exceeded.
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. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 (64494) provided on July 12, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and the removal of two (2) tooth implants (D6100) by an oral surgeon.
You asked the Plan to pre-approve a comprehensive oral evaluation and the removal of 2 tooth implants. You say that you need to see an oral surgeon as soon as possible as you are unable to eat without hurting your mouth and you are constantly in pain. You also say your eye and face are swelling. The Plan denied your request. The Plan says your contract with the Plan only provides coverage for dental services when they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, dental services performed by an oral surgeon are not covered. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and the removal of two (2) tooth implants (D6100) by an oral surgeon
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the patient is being
treated with goals to be discharged to a lower level of care. You say that therapy should continue to address the
deficits through training during activities like gait, stairs, balance and fall prevention. The Plan denied your
request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has previously been
treated with outpatient therapy and should be independent with a home exercise program. Our reviewer says
that the additional therapy services are not an appropriate duration and frequency for treatment of the member's
medical condition and are 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 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits
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
4, 2021, through March 22, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that this new code was established
to report additional practice expenses incurred during a public health emergency and the claims should be
reprocessed. 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 4, 2021, through March 22, 2021
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 requested admission to an IRF does not meet criteria.

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 you continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You are unable to bear weight on your left lower extremity and can receive services at a lower level of care. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services was not filed until July 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 lab services provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on March 22, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the medical services rendered on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 14, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 the services provided by an out-of-network provider on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injections rendered on June 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the chiropractor billed procedure code 20553 (trigger point injection). Therefore, we decided that the Plan does not have to pay for the trigger point injections rendered on June 25, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (77012) provided June 4, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says payment for this procedure is included in the primary procedure.
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 77012 is computed tomography guidance for needle
placement.
We find that CPT code 77012 is not supported in the medical record. Specifically, this procedure is included in
the primary procedure billed, CPT code 21899. Based on this information, we decided that Medicare rules for
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay
for radiology services (77012) provided June 4, 2021