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

 We decided that the Plan does not have to pay for the neuromuscular junction testing (95937) provided on June 23, 2021.  You asked the Plan to pay for the neuromuscular junction testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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.  In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.  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 neuromuscular junction testing. Our reviewer says that CPT code 95937 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report describes Train of Four was performed and reported with a neuromuscular junction procedure code. This is an incorrect code to report for Train of Four.  There is no procedure code for Train of Four, as this procedure is included in the primary neuromonitoring code, and therefore not separately reimbursed.  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 neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing (95937) provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.  You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the member has contraindications for coverage.  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 Vertiflex Superion Spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy.  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 Vertiflex Superion Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. There is no documentation to suggest a BiPAP with back up rate and AVAPS was utilized. The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a portable ventilator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent.  You asked the Plan to pre-approve the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that the member does not meet Medicare criteria for coverage of the requested procedure.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent. Our reviewer says that the follow up docototate scan is medically necessary and reasonable to assess the need for intervention. Our physician reviewer found the records indicate that this member has a neuroendocrine tumor and there was  a positive uptake docototate scan 6 months earlier. The documentation shows that the member elected no intervention.   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 radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent have been met. Therefore, we decided that the Plan has to pre-approve the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent.   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 pay for the ultrasound guidance (76937) provided on April 21, 2021.  You asked the Plan to pay for code 76937. 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. In this case, we have confirmed that code 76937 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 ultrasound guidance (76937) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99417 billed for date of service September 17, 2021.  You asked the Plan to pay for procedure code 99417. You have submitted medical records to support payment for this code. The Plan denied your request, saying this code was billed incorrectly. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, Medicare rules explicitly state that effective January 1, 2021, procedure code 99417 should not be used to bill for a prolonged evaluation and management service. Therefore, we decided that the Plan does not have to pay for procedure code 99417 billed for date of service September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthroscopy (29826) provided on March 30, 2021.  You asked the Plan to pay for the arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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.  In this case, the CPT Code Manual definition of code 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).  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 arthroscopy. Our reviewer says that CPT code 29826 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not describe subacromial space decompression and partial acromioplasty, and therefore 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 arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy (29826) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept Procedure.  You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration because you have been suffering from severe back pain. The Plan denied your request. The Plan says this procedure is not within the generally accepted standard of care for your condition.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational.  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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.  You asked the Plan to pre-approve the dental services. You say that it is noted in your file that you can get 4 deep cleanings per year. The Plan denied your request. The Plan says the upper left and upper right quadrants do not have 4 or more teeth requiring this service. The Plan also says that the frequency limit has been exceeded for the lower left and lower right quadrants.  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 the dental services when the services are medically necessary and reasonable.   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 dental services. Our reviewer says that scaling and root planing for the upper left and upper right quadrants is not medically necessary. Our physician reviewer found the requested code, D4341, requires 4 or more teeth in a quadrant to require scaling and root planing. The reviewer found that the provided documentation shows that less than 4 teeth require this service. Therefore, the reviewer found that the requested scaling and root planing for the upper left and upper right quadrants is not reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows that less than 4 teeth require this service in the upper left and lower left quadrants, and therefore are not covered. Additionally, scaling and root planing is covered once in a 24-month period, per quadrant. The record shows that the Plan paid for scaling and root planing for the lower left and lower right quadrants that you received on December 30, 2020, less than 24 months ago. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rotary wing ambulance transport (A0431), and rotary wing air mileage (A0436) provided on March 3, 2021.  You asked the Plan to pay for the transportation services. You say that the transport was medically necessary. The Plan denied your request. The Plan says the air transportation was not medically necessary.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 pay for the transportation services. Our reviewer says that the air transportation services are not medically necessary. Our physician reviewer found the provided documentation indicates the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The reviewer found that there is no documentation that the enrollee's condition was such that the time needed to transport the enrollee by ground or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered their health. The reviewer found that the enrollee had already undergone a thorough evaluation in the emergency room prior to the air ambulance transport including unremarkable laboratory testing and computed tomography of the head. His symptoms of confusion were resolved and he was back to baseline mental status. His vital signs were stable and his physical examination showed no acute abnormalities. Therefore, the reviewer found that the air transportation services are 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 transportation services have not been met. Specifically, the file shows that the enrollee was stable prior to receiving the air transportation services. Therefore, we decided that the Plan does not have to pay for the rotary wing ambulance transport (A0431), and rotary wing air mileage (A0436) provided on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for mass spectrometry testing (83789-59) provided on February 22, 2021.  You asked the Plan to pay for mass spectrometry test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this test is correct, because code 83789 is inclusive to codes 80307 and G0480 and the use of the -59 modifier is not supported.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service.    Specifically, the record does not show that this test was a distinct procedure service from the drug testing performed on this date. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for mass spectrometry testing (83789-59) provided on February 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) to a provider's office for a scheduled appointment.  You asked the Plan to pay for non-emergent ambulance transport. You say that the Centers for Medicare and Medicaid Services (CMS) COVID-19 protocol has temporarily expanded covered ambulance destinations to include provider's offices, and this claim should be paid. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled non-urgent visit is not a Medicare-covered benefit. Van transport or another vehicle may have been an option. The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.   The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. While CMS has issued certain flexibilities during the public health emergency to expand the list of covered destinations for ambulance transport, these provisions do not apply to a previously scheduled physician's appointment. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) to a provider's office for a scheduled appointment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crown (noble metal) (D6061) provided July 29, 2021.  You asked the Plan to pay for the abutment supported crown. You say that you don't understand why a crown is different if it's on an implant or a tooth. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 abutment supported porcelain fused to metal crown (noble metal) (D6061) provided July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on September 29, 2021.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that the Plan claims to cover dental x-rays, but the ones requested by the dentist were denied. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and/or provider eligibility.  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 complete series of intraoral x-rays (D0210) provided on September 29, 2021.   Your complaint about your unhappiness with the Plan's coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physician's services for external ocular photography with interpretation and report for documentation of medical progress, provided on July 19, 2021.  You asked the Plan to waive the copayment for physician's services. The Plan denied your request. The Plan says the $10.38 coinsurance applied correctly to the member's liability per the Evidence of Coverage.  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 50% of the Medicare-allowed amount for Physician/Practitioner services, including doctor's office visits, Specialist visit for Medicare-covered services out-of-network.   You have been asked to pay 50% of the Medicare-allowed amount for physician's services. The physician's services fall within the Physician/Practitioner services, including doctor's office visits, Specialist visit for Medicare-covered services out-of-network 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 physician's services for external ocular photography with interpretation and report for documentation of medical progress, provided on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography angiography (CTA).  You asked the Plan to pre-approve the CTA. You say that you would like reconsideration because the CTA is being requested for a Watchman workup. The Plan denied your request. The Plan says the documentation submitted does not include the results of other imaging.  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 CTA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found clinical guidelines for the use of CTA have not been met based on review of the submitted clinical documentation. The left atrial appendage occlusion device placement does not require preceding CTA imaging.    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 CTA have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography angiography (CTA).