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

 
We decided that the Plan does not have to pay for replacement of replaceable part of semi-precision or 
precision attachment of implant/abutment supported prosthesis, per attachment (D6091) and implant /abutment 
supported removable denture for edentulous arch mandibular (D6111) provided on June 8, 2022. 
 
You asked the Plan to pay for dental services. You say that you want what your plan pays for, and you do not 
think you should be paying for this. The Plan denied your request. The Plan says this service is not covered 
under your Plan. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Replacement of replaceable 
part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment 
(D6091) and implant /abutment supported removable denture for edentulous arch mandibular (D6111) are not 
covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested replacement of 
replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per 
attachment (D6091) and implant /abutment supported removable denture for edentulous arch mandibular 
(D6111) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for replacement of replaceable part of semi-precision or precision attachment of implant/abutment 
supported prosthesis, per attachment (D6091) and implant /abutment supported removable denture for 
edentulous arch mandibular (D6111) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 28, 2022.

You asked the Plan to pay for the dental services. You say that paying for this service would create a financial hardship. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted.

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, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service February 15, 2022. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided February 11, 2022.

You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management of the member's advance cancer. The Plan denied your request. The Plan says There is no documentation to support genetic testing on the billed 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 0037U is targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden.

We find that CPT code 0037U is not supported in the medical record. Specifically, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. A specimen was collected on July 16, 2021, rather than the billed date of service February 11, 2022. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided February 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99336) provided on December 31, 2021.

You asked the Plan to pay for the evaluation and management service. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the rest home visit (99336) provided on December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 88360 billed for date of service January 17, 2022.

You asked the Plan to pay for procedure code 88360. You say that you disagree with the denial. The Plan denied your request. The Plan says this code is included in the skilled nursing facility payment and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Technical components must be billed by the SNF for its Part A inpatients and are not separately payable.

The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee Schedule, CPT code 88360 has a Professional/Technical indicator of 1. This means that CPT code 88360 has both a professional and technical component. In this case, CPT code 88360 has not been billed with an appropriate modifier to indicate the professional component. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88360 billed for date of service January 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 1, 2022.

You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 83789 billed for date of service May 11, 2022.

You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480.

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 83789 is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 83789 billed for date of service May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided to the enrollee on June 23, 2022.

You asked the Plan to pay for the services. You say that the service was not included with another procedure. The Plan denied your request. The Plan says there are no modifiers allowed with this code pair.

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 99221 is a column II code to column I code 01214 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care provided to the enrollee on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on August 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that this dental procedure should be covered under 
your teeth cleaning benefit. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because the scaling of gingival inflammation is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on August 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the goal is to allow the enrollee a maximum opportunity of recovery and to assist with improving their outcome. You say that you foresee the LTACH level of care as a benefit and a means to prevent multiple re-admissions and manage the enrollee's ongoing medical complications. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

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 does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (AED) garment rendered on July 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed until July 27, 2022. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (AED) garment rendered on July 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to go to LTACH so they can be weaned off the ventilator they are on. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.

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 there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Health Plan. The Health Plan has approved ongoing care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 8, 2022.

You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.

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 procedure code 76705 billed for date of service July 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided on 
June 29, 2022.

You asked the Plan to waive the copayment for emergency room services. The Plan denied your request. The Plan says this cost sharing was charged correctly.

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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency room services. This service falls within the emergency care 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 emergency room services provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2022 billed with codes 81209, 81162, and 81201.

You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 21, 2022 billed with codes 81209, 81162, and 81201.
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 a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 that 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory tests provided on May 7, 2022.  
 
You asked the Plan to waive the deductible for laboratory tests provided on May 7, 2022. You say that that a 
mandatory physical examination was required, and nothing was submitted to Medicare. You are asking to have 
this revised. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $450 deductible which applies to laboratory tests.  
 
The item or service you asked the Plan to waive the copayment for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible which applies to laboratory tests. This cost sharing is a 
contractual obligation that had not been met at the time laboratory tests were provided on May 7, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for laboratory tests provided on  
May 7, 2022.
Appeal type: Lab
Decision: Unfavorable


We decided that the Plan does not have to pay for the genetic testing provided on May 6, 2021 billed with codes 81401, 81403, 81404, and 81405.

You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 6, 2021 billed with codes 81401, 81403, 81404, and 81405.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of conservative therapy.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Intracept device to established surgical decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment. In this case, the review has determined that the requested Intracept procedure is not medically reasonable or necessary for the enrollee.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.