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

 We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on October 18, 2021.  You asked the Plan to pay for dental services. You say that you do not feel like you should have to pay for this. The Plan denied your request. The Plan says services provided by an out-of-network provider 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. The Plan covers dental services when the services are provided by an in-network provider.  We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81479) provided March 15, 2021.  You asked the Plan to pay for the genetic testing. You say that this test was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.  The Plan must follow Medicare rules. Medicare rules say that SelectMDx is covered in males with a previous negative prostate biopsy being considered for a repeat prostate biopsy.  We looked at the file and Medicare rules. There is no record of a previous negative prostate biopsy. 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 (81479) provided March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluoroscopic guidance for central venous access device placement (CPT code 77001) provided to the enrollee on July 29, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  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 36901 is a column II code to column I code 77001. 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 fluoroscopic guidance for central venous access device placement (CPT code 77001) provided to the enrollee on July 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from December 31, 2021, through January 25, 2022.  You asked the Plan to pay for continuation of SNF services. You say that continuation of SNF services is medically necessary. The Plan denied your request. The Plan says SNF services provided from  December 31, 2021, through January 19, 2022 are 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 pay for continuation of SNF services provided from December 31, 2021, through January 19, 2022. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that you required continuation of skilled nursing services. You did not require and did not receive skilled therapy services. Daily skilled services were not required or provided. As a practical matter, you did not require the services on an inpatient basis, only in a skilled nursing facility setting. Continuation of services in the nursing facility appear custodial.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services provided from December 31, 2021, through January 19, 2022 have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from December 31, 2021, through January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services rendered on September 7, 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 00902 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.  In this case, the CPT Code Manual definition of code 00902 is anesthesia for; anorectal procedure.  We find that CPT code 00902 is not supported in the medical record. Specifically, there is no documentation to support anesthesia for an anorectal procedure.    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 anesthesia services rendered on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services (81455) provided on August 4, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis panel, hematolymphoid neoplasm, DNA analysis, 5-50 genes (CPT 81450) is a useful representation of the aggregate of these gene tests, and may be used as long as the panel contains, at a minimum, 5 or more gene tests for molecular biomarkers determined to meet Medicare coverage criteria.   We looked at the file and Medicare rules. In this case, more than 50 genes were tested, and billed with code 81455. The applicable LCA does not allow coverage for more than 50 genes. 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 the lab services (81455) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the discharge day management services provided on September 21, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code denied appropriately.  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 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status."   We find that CPT code 99217 is not billed as required. The case file does not include claim information for initial and/or subsequent observation care codes. 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 discharge day management services provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services billed for services provided on October 18, 2021.  You asked the Plan to pay for the billed services. You say that subarachnoid opioids are effective for decreasing pain. The Plan denied your request. The Plan says there are no records to support medical necessity.  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 62320 is not supported in the medical record. Specifically, there are no medical records to support the billed services. The file shows that the Plan made multiple attempts to obtain additional information with no success. Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services billed for services provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) for tooth #28 provided September 13, 2021.  You asked the Plan to pay for the crown. You say that you feel the new crown is your dentist's fault for not placing an adequate crown previously. The Plan denied your request. The Plan says you have exceeded the frequency limit 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. The Plan says that crowns may be replaced no earlier than 5 years after initial placement.  We looked at the file and Medicare rules. A crown for tooth #28 was previously placed on October 11, 2018.   Based on this information, we decided that the Plan's frequency limit for coverage of the crown has been exceeded. Therefore, we decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) for tooth #28 provided September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), panoramic x-ray (D0330), and 2D photographic images (D0350 x 4) provided on October 8, 2021, by the out of network provider.  You asked the Plan to pay for the dental services. You say that you were given 2 dentists by a plan representative. You say that you went to one of the offices you were told was in network. You say that after you received the services you were advised the provider was out of network. You also say that the services should be covered. The Plan denied your request. The Plan says dental services performed out of network 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, dental services performed out of network are not among those covered under this benefit. Additionally, complete series x-ray and 2D radiographic images are not covered regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), panoramic x-ray (D0330), and 2D photographic images (D0350 x 4) provided on October 8, 2021, by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic agents (64447 and 64450) provided on June 3, 2021.

You asked the Plan to pay for the anesthetic agents. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 64447, 64450 and 01462.

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 anesthetic agents. Our reviewer says that CPT codes 64447 and 64450 do not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation consists of a screen shot of injection given with patient locaton during procedure pre-procedure. In this case, there is not enough documentation to confirm Medicare Criteria for reporting anesthetic injection agent with anesthesia services on same date of service. Provider reported CPT 01462 anesthesia for all closed procedures on lower leg, ankle, and foot, with no anesthesia start and stop time documentation. Therefore, these procedures cannot be confirmed. 

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 anesthetic agents have not been met. Therefore, we decided that the Plan does not have to pay for the anesthetic agents (64447 and 64450) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on October 6, 2021.  You asked the Plan to pay for the dental services. You say that your previous dentist would not do anything unless you came up with $700. You say that you do not have extra money. You say that you need to keep your teeth from falling out and your jaw bone from dissolving. You also say that you still have money in your dental insurance so this should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits have been exceeded.  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 services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on August 11, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99202) radiologic examination, spine, cervical (72040) radiologic examination, spine, thoracic (72070) radiologic examination, spine, lumbosacral (72100) provided September 13, 2021.  You asked the Plan to pay for the chiropractic services. You say that you are trying to stay off drugs and doing anything to stay healthy. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.  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. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) radiologic examination, spine, cervical (72040) radiologic examination, spine, thoracic (72070) radiologic examination, spine, lumbosacral (72100) provided September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 4Kscore testing provided on September 1, 2021.  You asked the Plan to pay for the 4Kscore testing. You say that the provided 4Kscore testing on September 1, 2021, was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided 4Kscore testing provided on September 1, 2021.  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 pay for the 4Kscore testing. Our reviewer says that the enrollee did not meet criteria for the provided 4Kscore testing provided on September 1, 2021. Our physician reviewer found the provided 4Kscore testing on September 1, 2021, did not meet Medicare criteria. Specifically, the PSA was above 10 ng/mL and the records did not state whether or not other significant risk factors for prostate cancer were present.  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 4Kscore testing have not been met. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on April 19, 2021, through April 20, 2021.  You asked the Plan to pay for the outpatient hospital services as billed. You say that this was denied due to medical necessity. The records submitted support the services were medically necessary. The Plan denied your request. The Plan says the claim was denied due to an OCE edit which returns the claim to provider when modifier -CS is used on an ineligible code.  The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital claims are subject to the I/OCE. The quarterly data files are released with information about current OCE edits and how they affect claim payment.   In this case, this claim was denied in full due to OCE edit 114. The data files describe this edit has generated when "modifier CS is reported on an item or service that is not on the coinsurance  waiver eligible list". This list is also available in the data files and does not include code 71045 which was billed on this claim with modifier -CS. The data files indicate that this edit results in the claim being returned to the provider, meaning no payment is made. We find that this edit invoked correctly and denial of payment of this claim is supported. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on April 19, 2021, through April 20, 2021.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pay for the psychological or neuropsychological test administration and scoring by technician (96139) provided on August 16, 2021.  You asked the Plan to pay for the evaluation and management service. You say that the service should be paid. The Plan denied your request. The Plan says that says there was no documented contact with the enrollee's primary care physician.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   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 the evaluation and management service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the services in this case are medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the evaluation and management service have been met. Therefore, we decided that the Plan has to pay for the psychological or neuropsychological test administration and scoring by technician (96139) provided on August 16, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara device (E1399).

You asked the Plan to pre-approve a Volara device. You say that the item is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

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 Volara device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found high quality peer-reviewed supported evidence is not yet available for this device in the setting of this clinical scenario to generally approve. 

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 Volara device have not been met.

Therefore, we decided that the Plan does not have to pre-approve a Volara device (E1399).