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

We decided that the Plan does not have to pay for the testing services rendered on December 10, 2020.
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 codes 95955, 95885, 95908, and 95927 are 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. In this case, the CPT Code Manual definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is needle electromyography,
each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).
The definition of code 95908 is nerve conduction studies; 3-4 studies.
The definition of code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. We find that procedure codes 95955, 95885, 95908, and 95927 are not supported in the medical record. Specifically, there is no documentation of an EEG during intracranial surgery to support code 95955. There is no documentation of needle electromyography to support code 95855. There is no documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of short-latency somatosensory evoked potential study to support code 95927. 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 pay for the testing services rendered on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessible van items.
You asked the Plan to pre-approve wheelchair accessible van items. You say that the items in dispute are medically necessary and needed for transferring from your van to your power wheelchair. The Plan denied your request. The Plan says the requested items do not meet the Medicare criteria for durable medical equipment and cannot be approved.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessible van items.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the re-cement or re-bond of crown (D2920 x 2) provided on February 16, 2021.
You asked the Plan to waive the cost share amount for the dental service. You say that had you know that this provider had opted out of Medicare, you would have found a different provider. You say that in all your interactions with plan representatives, you were never advised that this was the case. You say that as a result, all your claims to date should be paid based on misinformation. The Plan denied your request. The Plan says there is a $100 deductible for covered comprehensive dental services. The Plan says that until you have paid the deductible amount, you must pay the full cost for covered dental services. The Plan says that you pay a 55% coinsurance for covered prosthodontic services that you receive out of network. The Plan also says that out of network providers may bill you up to the amount that they charge.
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 the service is listed as covered, cost sharing amounts still apply. The record shows that your full deductible was applied to the services in this case. The record shows that the Until you have paid the deductible amount, you must pay the full cost for covered dental services. Additionally, the deductible and coinsurance are contractual obligations you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share amount for the re-cement or re-bond of crown (D2920 x 2) provided on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services billed with diagnosis related group (DRG) 871 that were provided on February 2, 2019, to February 4, 2019.
You asked the Plan to pay for inpatient services billed with DRG 871. You say that the submitted DRG is correct. The Plan denied your request. The Plan says 149 is the appropriate DRG based on the record, as the primary diagnosis of Sepsis (A41.9) is not supported for this clinical encounter.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. DRG 871 requires a primary diagnosis of Sepsis. In this case, services were billed with DRG 871. 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 pay for inpatient services billed with DRG 871. Our reviewer says that the submitted DRG is not supported in the record. Our physician reviewer found despite presentation with fever and tachycardia, the hospital record did not support reporting the diagnosis code for Sepsis for this clinical encounter. The medical records do not support the billing of sepsis DRG 871. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services billed with DRG 871 have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services billed with diagnosis related group (DRG) 871 that were provided on February 2, 2019, to February 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 20, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says experimental/investigational services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed with code 81479 for coverage consideration. We looked at the file and Medicare rules. In this case, the requested Guardant360 testing was billed with multiple codes. Per the applicable LCA, Guardant360 testing must be billed with code 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 24, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says experimental/investigational services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed with code 81479 for coverage consideration. We looked at the file and Medicare rules. In this case, the requested Guardant360 testing was billed with multiple codes. Per the applicable LCA, Guardant360 testing must be billed with code 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0480) provided on May 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because this testing was ordered by the member's provider and medically necessary. The Plan denied your request. The Plan says authorization was not obtained for the billed 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 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 the drug testing services (G0480) provided on May 12, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided February 24, 2021.
You asked the Plan to pay for the diagnostic service. You say that please review the attached documentation showing that the exam on date of service 2/24/2021 is separate from the inpatient hospital stay from 02/05/2021 to 02/10/2021. The Plan denied your request. The Plan says payment for this service was included in the hospital contract rate.
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 enrollee was in an approved Part A covered skilled nursing facility stay from 02/10/2021 to 02/28/2021. The payment is included in the SNF prospective payment system. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided February 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing visits.
You asked the Plan to pre-approve skilled nursing visit. You say that the claim should be paid. The Plan denied your request. The Plan says the medical documentation did not support that the skilled nursing visit was necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no evidence that the enrollee had a new, acute problem, requiring care. As such, the health plan's denial should be upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that it is feasible to meet the member's needs at a lower level of care.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging, tomographic (SPECT) (78452) cardiovascular stress test (93015) provided May 17, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you would like to appeal the decision for the copay to be covered in full due to COVID related issue. You feel the provider did not include the COVID billing code in the claim that would make this covered in full. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $175 copayment for each Medicare covered advanced radiology service.
You have been asked to pay $175 copayment for the diagnostic services. The diagnostic services fall within the Outpatient diagnostic tests and therapeutic services and 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 copayment for the myocardial perfusion imaging, tomographic (SPECT) (78452) cardiovascular stress test (93015) provided May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 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 were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), two comprehensive oral evaluations (D0150 x2), complete series of intraoral x-rays (D0210), two first intraoral periapical x-rays (D0220 x2), additional intraoral periapical x-ray (D0230), anterior resin-based composite (D2331), posterior resin-based composite (D2392), crown (D2740), core buildup, including any pins when required (D2950), two periodontal scalings and root planings (D4341 x2), mandibular partial denture (D5214), complete maxillary denture adjustment (D5410), and mandibular partial denture adjustment (D5422) provided from January 26, 2021, to February 24, 2021 by an OON provider.
You asked the Plan to pay for the dental services. You say that you went to two other dentists for a second opinion, and the provider told you they were an in-network provider. You also say that you are on a fixed income and cannot pay for these services. The Plan denied your request. The Plan says the treating provider was not contracted on these dates of service. The Plan also says that your plan does not cover services rendered by a provider who is not in-network.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), two comprehensive oral evaluations (D0150 x2), complete series of intraoral x-rays (D0210), two first intraoral periapical x-rays (D0220 x2), additional intraoral periapical x-ray (D0230), anterior resin-based composite (D2331), posterior resin-based composite (D2392), crown (D2740), core buildup, including any pins when required (D2950), two periodontal scalings and root planings (D4341 x2), mandibular partial denture (D5214), complete maxillary denture adjustment (D5410), and mandibular partial denture adjustment (D5422) provided from January 26, 2021, to February 24, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 99100 and 66415.
You asked the Plan to pay for codes 99100 and 66415. You say that you disagree with the denial. The Plan denied your request. The Plan says these codes are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. In this case the claim submitted is missing the modifier required to allow these codes to be billed separately. Therefore, we decided that the Plan does not have to pay for the injection services rendered on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 physician services provided to the enrollee on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 14, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on December 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux for the enrollee.
You asked the Plan to pre-approve Erbitux. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Erbitux and Opdivo as second line treatment in the setting of squamous cell carcinoma have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Erbitux. Our reviewer says that Erbitux is not medically reasonable and necessary for the enrollee. Erbitux is not FDA approved for the enrollee's condition. Erbitux is not compendia approved for squamous cell cancer of unknown primary. In addition, Erbitux cannot be approved with Opdivo. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Erbitux.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 5, 2021 by a non-participating provider.
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 were rendered by a non-participating provider without prior authorization.
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 the office visit provided on April 5, 2021 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on January 8, 2021.
You asked the Plan to pay for the services provided. You say that all services should be covered under the hospital authorization number. The Plan denied your request. The Plan says the claim is not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We find that CPT code 73221 was billed with diagnosis codes M12.811 and M19.011. Diagnosis code M12.811 has an Excludes1 note for arthrosis (M15-M19). This means that the codes should never be used at the same time. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on January 8, 2021.