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

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 14, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.

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 71260 is a column II code to column I code 71275. 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 imaging services provided to the enrollee on August 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81321, 81406, 81408, 81162) provided March 3, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a genetic risk panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81321, 81406, 81408, 81162) provided March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 2, 2021.  You asked the Plan to pay for code 99153. 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. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placement of an implant (D6010) for teeth # 5, 6, 7, 18, 19, 20, 30 and 31.  You asked the Plan to pre-approve the implants. You say that the enrollee has a history of failed multiple partial dentures. You say this has resulted in the loss of more teeth and resorption of oral soft and hard tissue. You also say that implants are recommended for the comfort and confidence of the enrollee. The Plan denied your request. The Plan says implants 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 implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of an implant (D6010) for teeth # 5, 6, 7, 18, 19, 20, 30 and 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the elbow orthosis (L3761), provided on September 29, 2021.  You asked the Plan to pay for the elbow orthosis. You say that the item is medically necessary. The Plan denied your request. The Plan says there is evidence of misrepresentation.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery. the date of delivery does not match the date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the elbow orthosis (L3761), provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the placement of a permanent biventricular pacemaker.

You asked the Plan to pre-approve the placement of a permanent biventricular pacemaker. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says that the member does not meet Medicare criteria for coverage of the requested procedure.

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 pre-approve the placement of a permanent biventricular pacemaker. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have documented non-reversible symptomatic bradycardia due to sinus node dysfunction, or documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block. In addition, the enrollee does not have a nationally non-covered indication. the enrollee does have an indication for placement of a permanent biventricular pacemaker, based on 1862(a)(1)(A), given her NYHA Class III heart failure symptoms. This intervention has been shown to improve symptoms and survival in selected patients with advanced heart failure and cardiomyopathy.

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 placement of a permanent biventricular pacemaker have been met. Therefore, we decided that the Plan has to pre-approve the placement of a permanent biventricular pacemaker.

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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from February 19, 2021, to March 5, 2021.

You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan is denying payment for inpatient hospital services provided from February 19, 2021, to March 5, 2021, due to unbundling with denial code "G". However, the Plan has not shown that this is a Medicare rule to deny payment for inpatient hospital services. We find that the Plan has not substantiated their reasoning for the denial of payment for these services. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from February 19, 2021, to March 5, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00918) provided June 24, 2021.
You asked the Plan to pay for the anesthesia services. You say that the anesthesia services were medically necessary. The Plan denied your request. The Plan says coverage criteria 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. We find that CPT code 00918 is not supported in the medical record. Specifically, the anesthesia code billed does not correspond with the surgical procedure billed. CPT code 00910 is the correct anesthesia code for this service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00918) provided June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided on April 6, 2021, to April 12,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the surgery services. You say that you received phone calls from the non-
participating provider saying you needed the services. The Plan denied your request. The Plan says the services
provided was from a non-participating provider with no prior authorization. Also, there was no referral from an
in-network provider and the enrollee self-referred.
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 surgery services provided on April 6, 2021, to
April 12, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the SNF services.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require the services on an inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the
brain stem provided on October 28, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you feel the amount is incorrect since it
is more than what was charged as an inpatient. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.

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 a $250
copayment per day for diagnostic radiology services that are not ultrasounds.

You have been asked to pay $231.56, which is less than the $250 copayment for the MRI. The MRI falls 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 magnetic resonance imaging (MRI) of the brain stem provided on
October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80157, 80159, 80162, 80173, 80177, 80201) provided June 17, 2020.

You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 80157, 80159, 80162, 80173, 80177, & 80201 is not supported in the medical record. Specifically, the codes billed indicate a venipuncture service, however the lab reports the testing was performed with a urine sampling. 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 lab services (80157, 80159, 80162, 80173, 80177, 80201) provided June 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eye surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the eye surgery. You say that you have seen the out-of-network provider before and would like to have the surgery done by them. The Plan denied your request. The Plan says a list of multiple in-network providers was given to the enrollee who can provide the same 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 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 eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
services are not covered.
The Plan must follow Medicare rules. The rules say that wheelchair options and accessories are only covered
under certain medical indications.
The file shows that a power seat elevation system, elbow support pads, a color kit, and hub cap color were
requested. We looked at the file and the rules. This item is not primarily medical in nature. Based on this
information, we decided that the Medicare rules for coverage have not been met.
The file shows that a tubular back rest and an arm rest side support was requested. We find that the requested
items are bundled in to approved codes and are not separately reportable. Based on this information, we
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not
have to pre-approve wheelchair accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office consultation (99243) provided on July 21, 2021.  You asked the Plan to pay for code 99243. 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. Providers must report services with the appropriate CPT code.  We looked at the file and Medicare rules. In this case, CPT code 99243 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the office consultation (99243) provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Lipo-Mino injections.

You asked the Plan to pre-approve the Lipo-Mino injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medical Nutritional therapy is not covered for the member's condition.

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 Lipo-Mino injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Lipo-Mino is not considered a medically reasonable standard of practice for weight loss in the peer reviewed literature. The documentation does not support that the Lipo-Mino is safe and effective for the member.

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 Lipo-Mino injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Lipo-Mino injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided June 17,
2021.
You asked the Plan to pay for the diagnostic service. You say that these procedures were rendered 3 times on
this date of service at different times. The Plan denied your request. The Plan says the information provided
does not support the frequency within this time period.
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 71045 is radiologic examination, chest.
We find that CPT code 71045 is not supported in the medical record. Specifically this claim did not include the
required 59 or XE modifier in addition to modifier 76 on the 3rd claim for repeated subsequent services. 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 the radiologic examination, chest (71045)
provided June 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on August 25, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on August 7, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from SNF care.
The Plan denied your request. The Plan says Medicare criteria for SNF admission are not met.
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 daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's
functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of
a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF.
The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a
"daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an
inpatient basis, in a skilled nursing facility 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 admission to a skilled nursing facility (SNF).