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

We decided that the Plan does not have to pay for the psychotherapy services coded as 90840 provided on March 22, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was billed without the 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 90840 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 psychotherapy services coded as 90840 provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on February 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
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 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 use of code 97110 is not supported by the records provided. Our reviewer found that the physical therapy assistant visit documents that therapy was performed in the enrollee's home. CPT 97110 is inappropriate to report for this service. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for a physical therapy assistant, and services performed in the home.
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 the services (97110) provided on February 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cataract surgery provided on January 6, 2021.

You asked the Plan to waive the deductible for the cataract surgery. You say that you do not have a deductible for an outpatient hospital, and you believe that the claim was processed as inpatient. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 $750 deductible that applies towards in-network outpatient hospital services.

The cataract surgery you asked the Plan to waive the deductible for falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the cataract surgery. This cost sharing is a contractual obligation that had not been met at the time the cataract surgery was received on January 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the cataract surgery provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $65 copayment charged for urgent care services provided
on June 27, 2021.
You asked the Plan to waive these services. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment is a contractual obligation.
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 $65
copayment for urgent care services. 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 $65 copayment charged for
urgent care services provided on June 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0457) provided April 1, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the items 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. 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. No itemized shipping documentation was provided. 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 an orthosis (L0457) provided April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemodenervation services provided on March 8, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64615 is 1. The MAI value for this code is 2. You billed 2 units of this code on the date of service at issue, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the chemodenervation services provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle libre continuous glucose monitoring (CGM)
system and supplies
You asked the Plan to pre-approve the CGM system and supplies. You say that you are a type one diabetic and
have no way of managing this health issue without knowing your glucose, so you can make adjustments. You
are concerned about your health being at risk without this item you need. The Plan denied your request. The
Plan says the records show that the enrollee does not meet coverage criteria for a Freestyle Libre.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM system and supplies. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the plan requires 3 shots of insulin and frequent adjustments in the insulin
doses based on blood glucose, this is not the case now. With time she may become more dependent on multiple
daily injections with a sliding scale, in which case she will qualify for CGM however, at this time as of the
dates of the provided notes, this is not the 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 the CGM system and supplies have not been met. Therefore, we decided that
the Plan does not have to pre-approve Freestyle libre continuous glucose monitoring (CGM) system and
supplies
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure 74176) provided to the enrollee on June 7, 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 correct modifier was not billed in this case.

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 74176 is "Computed tomography, abdomen and pelvis; without contrast material." 

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 CPT 74176 is bundled with CPT 74174 which was performed on the same date of service. A modifier is allowed to unbundle these services, providing the medical records has sufficient documentation to support the use of a modifier. However, a modifier was not used when billed to unbundle 74176 from 74174, therefore no additional payment is allowed for 74176. 

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 imaging services (procedure 74176) provided to the enrollee on June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).
You asked the Plan to pre-approve the PET scan. You say that you are asking for reconsideration of the previous decision and allow coverage for this test. The Plan denied your request. The Plan says the notes do not support that the procedure is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee had a chest CT on 8/17/2021 showing a few tiny nodules that were not seen on the previous chest CT. The report raises a question of metastatic malignancy. However, according to the report, the largest of the new nodules is 4 mm. PET scan is not considered diagnostically useful for nodules smaller than 10 mm. This enrollee does not have a known primary malignancy. The radiologist's recommendation is repeat CT imaging in 6 months, and that would seem to be the most appropriate action. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tooth extractions (D7140), endosteal implants (D6010),
prefabricated abutment (D6056), metal crown restorations (D6059), and porcelain fused to metal (D6240)
provided by an out-of-network provider on March 8, 2021.
You asked the Plan to pay for tooth extractions, endosteal implants, prefabricated abutment, metal crown
restorations, and porcelain fused to metal. You say that you disagree with this denial. You say that you would
like the Plan to reimburse you for these services. The Plan denied your request. The Plan says these services
have been correctly denied. The Plan says that the rendering dentist is out-of-network.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers tooth
extractions, endosteal implants, prefabricated abutment, metal crown restorations, and porcelain fused to metal
when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of tooth extractions, endosteal implants, prefabricated abutment, metal crown restorations, and
porcelain fused to metal have not been met due to this provider being out-of-network. Therefore, we decided
that the Plan does not have to pay for tooth extractions (D7140), endosteal implants (D6010), prefabricated
abutment (D6056), metal crown restorations (D6059), and porcelain fused to metal (D6240) provided by an
out-of-network provider on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular gene panel provided on April 15, 2021.
You asked the Plan to pay for the testing services. You say that the service is separately payable. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels with suspected or documented cardiovascular disease.
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. We looked at the file and the rules. All cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented cardiovascular disease because panel testing is not specific to a given patient's lipid abnormality or disease. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular gene panel provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (TENS) device, pneumatic compression device (PCD) and compound drug injections rendered on April 5, 2021.
You asked the Plan to pay for these medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that TENS therapy is covered for chronic low back pain when part of an approved clinical study. The rules say that PCDs are covered for the treatment of lymphedema. The rules say that compound drugs must be coded with a NOC code. We looked at the file and Medicare rules. In this case, the enrollee is not enrolled in a clinical study as required for TENS therapy and is not using the PCD for the treatment of lymphedema. In addition, the compound drugs have not been billed with the required NOC code. Based on this information, we decided that Medicare rules for coverage of these medical services have not been met. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (TENS) device, pneumatic compression device (PCD) and compound drug injections rendered on April 5, 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 is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of 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 not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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: 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 you disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for a stroke and surgical management of a trimalleolar fracture and discharged to a skilled nursing
facility on October 13, 2021. She is now medically stable with no complex nursing or rehabilitation needs. She
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
There is not a reasonable expectation that 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a left hip arthroplasty and will need inpatient admission after surgery The Plan denied your request. The Plan says there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you are approved for a left hip arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology, selective cellular enhancement technique with interpretation (88112) rendered by the out-of-network (OON) provider on May 6, 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 cytopathology, selective cellular enhancement technique with interpretation (88112) rendered by the out-of-network (OON) provider on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 18, 2020.
You asked the Plan to pay for the services provided. You say that the testing is used for clinical purposes. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
The provided claim lists a place of service as an office. The records provided do not indicate the lab specimen was obtained at an office. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron ODT for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron ODT for the enrollee.