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

We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on 
March 5, 2021, billed with code 76700. 
 
You asked the Plan to pay for the abdominal ultrasound interpretation. You say that this should be payable. The 
Plan denied your request. The Plan says this was not billed with the necessary modifier. 
 
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only 
the Column 1 code is payable unless a clinically appropriate modifier is used. 
 
We looked at the file and Medicare rules. Code 76700 is a Column 2 code in relation to code 93976 which was 
also billed on this date of service. No clinically appropriate modifier was used to justify bypassing this edit. 

Based on this information, we decided that Medicare rules for coverage of the abdominal ultrasound 
interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation 
of the abdominal ultrasound provided on March 5, 2021, billed with code 76700.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on May 9, 2021. 
 
You asked the Plan to pay for the head CT interpretation. You say that this service should be payable. The Plan 
denied your request. The Plan says this service was not billed with the required modifier. 
 
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only 
the Column 1 code is payable unless a clinically appropriate modifier is used. 

We looked at the file and Medicare rules. Code 70450 is a Column 2 code in relation to code 70496 which was 
also billed for this date of service. No clinically appropriate modifier was used to justifying bypassing this edit. 
Based on this information, we decided that Medicare rules for coverage of the head CT interpretation have not 
been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the computed 
tomography (CT) scan of the head provided on May 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth 
#30. 
 
You asked the Plan to pre-approve the crown (D2740) and core buildup (D2950). You say that the contact 
between tooth #30 and #31 is wide open which is leading to food trap issues, gingival inflammation and 
speeding up the bone loss process. You say that a replacement crown is in the patient's best interest and the 
denial should be reconsidered. The Plan denied your request. The Plan says there is no indication that there is 
anything wrong with the existing crown on #30. Code D2950 is used when preparing a tooth for a crown. The 
Plan also says that without an approved crown the core buildup is also denied. 
 
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 crown 
(D2740) and core buildup (D2950) 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 core buildup (D2950) and crown 
(D2740). Our reviewer says that coverage for crowns is not provided when used for cosmetic reasons or for 
closing gaps. Our physician says that the documentation does not support that the enrollee has extensive decay 
or destruction of the tooth. Core build up is provided in preparation for a crown. Since the crown is not covered 
the core buildup is also not covered. 
 
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 core buildup (D2950) and crown (D2740) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth #30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 weakness and falls after a recent Coronavirus infection. 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 documentation
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 acute IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sphenopalatine ganglion block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary to relieve headache pain. 
The Plan denied your request. The Plan says there is no evidence in the peer-reviewed literature that this 
procedure has better outcomes compared with conventional standard treatments. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this therapy is based on anecdotal evidence only. It is considered experimental and investigational. 
Therefore, the request is deemed not medically reasonable or 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sphenopalatine ganglion block for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on March 1, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the Medicare
rule for payment has not been met.

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 99601 is home infusion/specialty drug administration, per
visit (up to 2 hours). We find that CPT code 99601 is not valid for Medicare purposes. Medicare uses another
code for the reporting of, and payment for, these services. 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 home infusion services provided on March 1, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit for dental services.

You asked the Plan to pre-approve the services. You say that this is medically necessary, as there is pain and you are not eating well. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an office visit for dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 18, 
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 must 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 services provided to the enrollee on 
May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) provided on May 3, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you had major bone 
loss on your upper jaw, and you were referred to the oral surgeon for reconstruction. You also say that you feel 
this service should be paid under your medical benefit. The Plan denied your request. The Plan says this service 
is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify 
benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0364) provided on May 3, 2021.  
 
Please Note: The Plan forwarded this appeal information to the medical team to see if it can be covered under 
your medical plan. Please contact the Plan for more information.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided to the enrollee on June 23, 2021.

You asked the Plan to pay for the ultrasound. You say that the enrollee has multiple exams on this date of service. 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. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76705 and 76700. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. 

However, both the primary procedure 76700 and appealed bundled code 76705 have been billed with a modifier of 26. This modifier is not included in the list of NCCI-allowed modifiers as stated in the NCCI Policy Manual for Medicare. Therefore, the plan has determined to uphold the denial of 76705 as the appealed CPT code was not billed with a NCCI-allowed modifier and is considered bundled into the payment of 76700. Therefore, we decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided to the enrollee on June 23, 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 January 5, 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 services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on February 16, 2021. 
 
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that you were not aware that 
the provider had opted out of Medicare. The Plan denied your request. The Plan says the requested provider has 
opted out of Medicare. 
 
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 periodic oral evaluation and prophylaxis have not been met. We have confirmed that the provider 
opted out of Medicare on March 30, 2016. This means that the provider was opted out of Medicare for the date 
of service at issue. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on February 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. 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 6 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 you have had prior therapy and have been 
authorized therapy to ensure competence in a home exercise program. Our reviewer says that the unique skills 
of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this feature is 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 a power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 31. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound, transvaginal (CPT code 76830-76) provided 
to the enrollee on June 9, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee had a transvaginal ultrasound on June 9, 2021. The submitted 
documentation supports one (1) unit of 76830, which was previously approved/paid. There is no additional 
documentation supporting an additional study which was billed and remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the file shows that the enrollee had a transvaginal ultrasound on June 9, 2021. The submitted 
documentation supports one (1) unit of 76830, which was previously approved/paid. There is no additional 
documentation supporting an additional study which was billed and remains denied. Based on this information, 
we decided that Medicare rules for coverage of the ultrasound have not been met. 

Therefore, we decided that the Plan does not have to pay for the ultrasound, transvaginal (CPT code 76830-76) 
provided to the enrollee on June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus laboratory test (U0002) provided on May
10, 2021.
You asked the Plan to pay for the Coronavirus laboratory test. You say that you do not agree with the claim
determination and would like to appeal. The Plan denied your request. The Plan says this code is 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 Current Procedural Terminology (CPT) code.
In this case, the CPT Code Manual definition of code U0002 is 2019-ncov coronavirus, sars-cov-2/2019-ncov
(covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc.
We find that Healthcare Common Procedure Coding System (HCPCS) code U0002 is not supported in the
medical record. Specifically, HCPCS code U0002 was billed on the same claim as CPT code 87635. The
record shows that CPT code 87635 for Coronavirus testing was previously processed and paid by the Plan. It is
not appropriate to report the HCPCS code and CPT code for Coronavirus testing on the same claim. Based on
this information, we decided that Medicare rules for coverage of the Coronavirus laboratory test have not been
met. Therefore, we decided that the Plan does not have to pay for the Coronavirus laboratory test (U0002)
provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2204, V2208, S0590) provided on June 5, 2021.
You asked the Plan to pay for the eyeglasses. You say that you thought you could get eyeglasses every year rather than every two years, and you say the Plan pre-approved these services. The Plan denied your request. The Plan says you previously received a pair of eyeglasses in February of 2020, which is less than two years before the date in question. Routine eyewear can only be covered once every two years. The Plan also states that there was no pre-approval requested or completed prior to these services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once every two calendar years. We looked at the file and the Plan's rules. Documentation shows that you previously received a pair of routine eyeglasses in February 2020, which was paid for by the Plan. In addition, no documentation of a prior approval was provided for review. The Plan covers routine eyewear once every two calendar years. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2204, V2208, S0590) provided on June 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic supplies for the enrollee.
You asked the Plan to pre-approve diabetic supplies. You say that these supplies are medically necessary for
the enrollee. The Plan denied your request. The Plan says insufficient medical records were submitted to
support this request. Maximus overturned the Plans denial. The Plan requested a reopen and stated that they
provided documentation to show they tried repeatedly to request medical records needed to support the diabetic
supplies requested.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Insufficient medical records were submitted to support the items requested. The Plan
provided documentation to show several attempts were made by the Plan to retrieve the records needed and
those requests were not responded to. Based on this information, we decided that Medicare rules for coverage
of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve
diabetic supplies for the enrollee.