Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on July 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the acupuncture services. You say that the services should be covered and you should be reimbursed. The Plan denied your request. The Plan says the services denied correctly as the provider is out-of-network and there is no authorization on file.
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 acupuncture services provided on July 17, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health problem.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been approved for anterior lumbar interbody fusion with posterior hardware extension. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. Therefore, the request for bone marrow aspiration is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two excisions of benign lesions (D7410 x2) and consultation (D9310) provided on October 7, 2021.
You asked the Plan to pay for the excisions of benign lesions and consultation. You say that you feel that the charges should be approved since it was referred and a preventive measure to rule out cancer. You also say that you are on disability and on a limited income. The Plan denied your request. The Plan says these services are not covered expenses under your dental 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.
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 two excisions of benign lesions (D7410 x2) and consultation (D9310) provided on October 7, 2021
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve allograft for spine surgery for the enrollee.
You asked the Plan to pre-approve the services. You say that this is the standard of care to use a plate when performing an anterior cervical fusion. The Plan denied your request. The Plan says that this is not medically necessary.
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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found structural allograft is an acceptable bone graft option for the requested surgery with a plate. It should be approved. 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 been met. Therefore, we decided that the Plan has to pre-approve allograft for spine surgery for the enrollee.
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: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has previously failed at a lower level of care and is expected to need additional time in a hospital setting due their high risk. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your functional improvement had plateaued by February 16, 2022 and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of February 16, 2022, you required custodial services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27540) provided April 1, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 find that CPT code 27540 is not supported in the medical record. Specifically, the code billed is part of the primary procedure and not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27540) provided April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal injection provided on August 9, 2021.
You asked the Plan to pay for the spinal injection. You say that this treatment is accepted as medically necessary for the enrollee's condition. The Plan denied your request. The Plan says no records were submitted to support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. No medical records were submitted for review. As such, it cannot be confirmed that coverage criteria are met. Based on this information, we decided that Medicare rules for coverage of the spinal injection have not been met. Therefore, we decided that the Plan does not have to pay for the spinal injection provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on October 4, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you were told that there was no cost for the shingles vaccine. The Plan denied your request. The Plan says the administration fee was paid; however, the vaccine itself is only covered by Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on October 4, 2021.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) (D0364) 
provided on October 13, 2021.
You asked the Plan to pay for the dental service. You say that the provider determined this service was 
necessary to determine if a repair or re-treatment for a root canal was needed. You also say this should be 
covered. The Plan denied your request. The Plan says cone beam CT is not listed as a covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT is 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) (D0364) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride (D1208) provided on October 5, 2021.
You asked the Plan to pay for the application of fluoride. You say that you and your husband have the same coverage and received services from the same dentist. You say that your husband's claim was covered and yours was not. You also say that this dentist is in network. The Plan denied your request. The Plan says application of fluoride is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the application of fluoride is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride (D1208) provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided May 27, 2021.
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 records do 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 G0483 is not supported in the medical record. Specifically, the place of service listed on the claim (81, lab) does not match the place of service detailed in the records (11, office). 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 (G0483) provided May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-SCC testing (81599) provided on September 7, 2021.
You asked the Plan to pay for the DecisionDx-SCC. You say that you would like reconsideration because this testing is covered by Medicare and was billed appropriately. The Plan denied your request. The Plan says this testing was not billed with the correct CPT code.
The Plan must follow Medicare rules. Medicare rules say that only approved tests will be reimbursed consistent with the effective date of the coverage determination.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC have not been met. Specifically, this lab is located in a MoIDX governed state. Per the diagnostics exchange, this test is not covered. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (81599) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an epidural steroid injection (62320) provided on August 16, 2021.  You asked the Plan to pay for an epidural steroid injection. You say that this is part of a comprehensive pain management program. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that in order for epidural steroid injections to be covered, the procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.  We looked at the file and Medicare rules. The percent pain relief achieved immediately post-injection is not documented in the submitted records. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pay for an epidural steroid injection (62320) provided on August 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on October 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 76705 is a column II code to column I code 93976. 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 services (76705) provided on October 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance for a spinal injection (77003) provided on June 15, 2021.
You asked the Plan to pay for the fluoroscopic guidance for a spinal injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77003 was not billed with an appropriate primary procedure code.
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 the fluoroscopic guidance for a spinal injection is an add-on code and has not been billed with an appropriate primary procedure code. 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 a spinal injection (77003) provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 18,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and
should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for
these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 62320 billed for date of service October 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any parental medication, complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the insertion tray and urinary catheter anchoring device (A4314, A4333) provided on June 14, 2021.
You asked the Plan to pay for the insertion tray and urinary catheter anchoring device. You say that you would like reconsideration because these supplies are delivered in 3-month increments and are medically necessary. The Plan denied your request. The Plan says that the enrollee received the services during or in preparation for a procedure or surgery at the facility.
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. Specifically, the Plan's denial indicates that this equipment is included in the payment to the facility for a procedure. The Plan has not forwarded any evidence that these supplies were used for the preparation of a procedure or service. The Plan has not forwarded any indication that the member had a procedure on the billed date of service. Additionally, the supplies at issue would not be used to prepare for surgery. It is the burden of the Health Plan to substantiate their denial with evidence. In this case the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the insertion tray and urinary catheter anchoring device (A4314, A4333) provided on June 14, 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.