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

We decided that the Plan does not have to pay for the drug test (G0483) rendered by the out-of-network (OON)
provider on July 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the drug test (G0483) rendered by the out-of-network (OON) provider on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Optimizer Smart IPG (CPT code 0408T).  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, our physician reviewer would not consider the CCM system to be medically necessary for you.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve Optimizer Smart IPG (CPT code 0408T).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95938, 95908, 95886) provided
June 17, 2021.
You asked the Plan to pay for the neuromonitoring services. You say that these services were medically
necessary. The Plan denied your request. The Plan says these services are 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 CPT code.
We find that CPT code 95938, 95908, & 95886 is not supported in the medical record. Specifically, the
provider taxonomy is not eligible for Medicare payment. Payment for this service was made to the facility.
Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have
not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95938,
95908, 95886) provided June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is the necessary next level of care. The Plan
denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the
enrollee could receive care in another setting.
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 the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require physical therapy and occupational therapy services but does not require an intensive inpatient
rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72040) provided August 2, 2021.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied
your request. The Plan says this service is not covered when performed 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 an x-ray (72040) provided August 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued HHS from January 28, 2022, forward.  You asked the Plan to pre-approve the services. You say that you want your aid to come back and assist you. The Plan denied your request. The Plan says your current needs appear not be skilled in nature.  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 the services. Our physician reviewer found the health plan's denial should be upheld. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You live in a care facility. You refuse to fully participate in skilled services are general care. As such, ongoing HHS are not medically necessary or reasonable.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued HHS from January 28, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit provided on September 8, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the outpatient visit provided by an OON provider. You say that you would like
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 the outpatient visit provided on September 8,
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services (99601) provided on September
2, 2021.
You asked the Plan to pay for code 99601. 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 99601 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 home infusion services (99601) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation service provided from July 25, 2021, through July 26, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the enrollee must pay a $300 copayment for outpatient hospital observation services. The emergency room copayment is waived if the enrollee is placed in an observation status.
The enrollee has been asked to pay a $210 copayment ($300 - $90) for the hospital observation service provided. The original copayment applied in this case was $300 with the waiver of the $90 copayment for the emergency room service provided. The Plan contract states that the emergency room copayment is waived if the enrollee is placed in an observation status. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital observation service provided from July 25, 2021, through July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination (71045-26) provided on July 9,
2021.

You asked the Plan to pay for code 71045-26. 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 if more than one service is provided on the same
day to the same patient by the same physician or more than one physician in the same specialty in the same
group, only one service may be reported unless the services are for unrelated problems. Based on the
documentation provided, this claim cannot be paid as billed due to the physician group relationship between the
two providers and the omission of the modifier required to identify this as a separate and distinct service.
Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for the
radiologic examination (71045-26) provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), gingival irrigation per quadrant (D4921), localized delivery of antimicrobial agents (D4381) and drugs or medicament's dispensed in the office for home use (D9630) provided on June 8, 2021.
You asked the Plan to pay for periodontal scaling and root planing, gingival irrigation per quadrant, localized delivery of antimicrobial agents and drugs or medicament's dispensed in the office for home use. You say that the provider did not check eligibility, benefits or submit the verification of treatment plan. You also say you were not told that these services would not be covered, and you cannot afford the invoice. The Plan denied your request. The Plan says you have exhausted your benefit for a periodontal scaling and root planing. The Plan also says that gingival irrigation per quadrant, localized delivery of antimicrobial agents and drugs or medicament's dispensed in the office for home use are not covered benefits with your Plan.
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. The records show that you received a periodontal scaling and root planing on March 7, 2019, therefore, you have exhausted your maximum benefit for this service. The EOC confirms that gingival irrigation per quadrant, localized delivery of antimicrobial agents and drugs or medicament's dispensed in the office for home use are not listed as covered benefits with your Plan. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing, gingival irrigation per quadrant, localized delivery of antimicrobial agents and drugs or medicament's dispensed in the office for home use have not been met. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), gingival irrigation per quadrant (D4921), localized delivery of antimicrobial agents (D4381) and drugs or medicament's dispensed in the office for home use (D9630) provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the autograft for spine surgery (20936), lower spine disk x-ray (72295) and fluoroscopy (76000) provided on January 5, 2021.
You asked the Plan to pay for the autograft for spine surgery (20936), lower spine disk x-ray (72295) and fluoroscopy (76000). You say that the records are attached, and the claim should be processed for payment. The Plan denied your request. The Plan says CPT code 20936 is considered a bundled service and not separately payable. CPT code 72295 and 76000 are considered inclusive to CPT code 22558.
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 20936 is autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 72295 is discography, lumbar, radiological supervision and interpretation. The CPT Code Manual definition of code 76000 is fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time. 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 autograft for spine surgery (20936), lower spine disk x-ray (72295) and fluoroscopy (76000). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that CPT code 72295 would not be reported, as radiology services are performed during the lumbar arthrodesis. CPT code 76000 would also not be reported separately from lumbar arthrodesis, as radiology procedures would be performed during the arthrodesis procedure. We find that CPT code 20936 is not supported in the medical record. Specifically, CPT code 20936 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable.
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 autograft for spine surgery (20936), lower spine disk x-ray (72295) and fluoroscopy (76000) have not been met. Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery (20936), lower spine disk x-ray (72295) and fluoroscopy (76000) provided on January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management services
(procedure code 99217) provided to the enrollee on August 31, 2021.
You asked the Plan to pay for the services. You say that the medical records support the frequency of services
rendered. The Plan denied your request. The Plan says the procedure code was not correct for this date of
service.
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." To report services
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236
as appropriate.])"
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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found the medical records provided does not
include sufficient documentation to validate that 99217 was performed on August 31, 2021, therefore this
service cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for observation care discharge day management services (procedure code 99217) provided to the
enrollee on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on October 5, 2021.
You asked the Plan to pay for the resin-based composite. You say that there is still a dollar amount available to cover this claim. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has 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, restorations (fillings) are limited to two procedure codes per calendar year. The record shows that you received two resin-based composites on March 2, 2021 and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2393) provided on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan (74177) provided on August 14,
2021.
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as
you were informed your copayment would only be $40 beforehand. The Plan denied your request. The Plan
says the cost-sharing applied correctly based on the services provided.
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 $265
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $265 copayment for a CT scan. The record indicates that you did contact the
plan. However, there is no record of you asking about a CT scan copayment. CT scans 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 a CT scan (74177) provided on August 14,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as a skilled nursing facility.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.