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

We decided that the Plan does not have to pay for administration charges for the Shingles vaccine you received on November 19, 2021.
You asked the Plan to pay for the Shingles vaccine administration charges. You say that you were told this would be covered if you received the vaccine in a doctor's office. The Plan denied your request. The Plan says the Shingles vaccine and its administration is not covered under your medical benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine or administration charges. 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 administration charges for the Shingles vaccine you received on November 19, 2021.
Benefits for the Shingles vaccine administration charges 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 comprehensive oral evaluation (D0150) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were advised that the appointment was fully 
paid for by having dental insurance through your plan. The Plan denied your request. The Plan says 1 
comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has 
been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 9, 2020. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on July 13, 2021. 
 
You asked the Plan to pay for code 83789. 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, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. We find that tests to confirm that a urine specimen is not adulterated is not separately billable. Therefore, we decided that the Plan does not have to pay for the Mass spectrometry 
and tandem mass spectrometry (83789) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97813) acupuncture, each 
additional 15 minutes (97814) provided October 18, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that these services were medically necessary 
and reported correctly. The Plan denied your request. The Plan says the services were rendered by a no-covered 
provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the contract says that the services must be provided 
by a legally qualified physician practicing within the scope of their license. The services were rendered by a 
licensed acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay for 
acupuncture, initial 15 minutes (97813) acupuncture, each additional 15 minutes (97814) provided October 18, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided to the enrollee on July 29, 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 denied code is inclusive to another 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 23430 is a column II code to column I code 23472. 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 inpatient services provided to the enrollee on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100) provided on June 1, 2021. 
 
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100) provided on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for temperature gradient studies (procedure code 93740) 
provided to the enrollee on May 26, 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 separate payment is never made for routinely billed services and supplies. 
 
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 93740 is "Temperature gradient studies." 
 
We find that CPT code 93740 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment 
for other services not specified. 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 temperature gradient 
studies (procedure code 93740) provided to the enrollee on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary. We looked at the file and Medicare rules. The services are billed under code 81455. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport services provided on August 18, 2021. 
 
You asked the Plan to pay for the ambulance transport services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 ambulance transport services provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on October 4, 
2021, for tooth #8. 
 
You asked the Plan to pay for the crown. You say that this crown was medically necessary. The Plan denied 
your request. The Plan says your x-rays do not show that this tooth has decay or loss due to fracture involving 
more than 50% of the biting edge of the tooth. Also, this tooth has less than 50% bone support. The clinical 
requirements for coverage of a crown are not met in this case. 
 
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. The Plan covers the crown 
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 pay for the crown. Our reviewer says that this tooth 
did not meet the criteria for coverage of a crown. Our physician reviewer found that the supplied x-rays reveal 
that tooth #8 appears to be essentially intact with some lingual wear appearing as an increased radiolucency in 
the cingulum area. The tooth also has noted bone loss with only about 35% of the support remaining. A crown is not usually considered where there is minimal missing or damaged structure, and the tooth could reasonably 
be restored with a conventional composite or amalgam restoration. In this case there is minimal missing 
structure and there is no need to cover the tooth to gain strength. In addition, the lack of bone support makes 
the prognosis for this tooth poor and should not be considered for a crown restoration. The Plans criteria for a 
crown have not been met in this case. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pay for the porcelain/ceramic crown (D2740) provided on October 4, 2021, for tooth #8.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (33274) provided May 24, 2021 to May 25, 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 claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 33274 is not supported in the medical record. Specifically, no clinical trial number was included on the claim form submitted. 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 (33274) provided May 24, 2021 to May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bladder irrigation, simple, lavage and/or instillation (51700) 
provided June 18, 2020. 
 
You asked the Plan to pay for the procedure. You say that please review the attached documentation and 
process the claim accordingly. The Plan denied your request. The Plan says unites billed exceed the allowed 
number of units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that the billed amount exceeds the allowed number of units in one day. The records show that CPT 
code 51700 had already been paid for by the Plan on claim processed on 7/04/2020. 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 pay for Bladder irrigation, simple, lavage and/or instillation (51700) provided June 
18, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the documentation supports those services may be provided 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 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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the medical records provided there is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on September 8, 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 procedure code 97530 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. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the file shows that the services were rendered in the home setting and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the occupational therapy services rendered on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0037U) provided on September 8, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says these out-of-network services were not pre-authorized.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (0037U) provided on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 Receiver.
You asked the Plan to pre-approve a Dexcom G6 Receiver. You say that the member needs this item. The Plan denied your request. The Plan says there is no medical reason the member needs the requested item over the Plan preferred brand.
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers. 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 Dexcom G6 Receiver. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no medical reason the member needs the requested item over the Plan preferred brand. 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 Dexcom G6 Receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 Receiver.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for incision procedures on the middle ear 
provided on March 8, 2021. 
 
You asked the Plan to pay for physician's services for incision procedures on the middle ear. The Plan denied 
your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the members terminal condition. The Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. During the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness until the first day of the month following the month in which hospice was 
revoked or discharged. 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 physician's services for incision procedures on the middle ear 
provided on March 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological supervision services (procedure code 75716) 
provided to the enrollee on July 22, 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 procedure code 75716-59 is not supported by the medical records submitted. 
 
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 75716 is "Angiography, extremity, bilateral, radiological 
supervision and interpretation." 
 
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 there is abundant documentation of 
selective left lower extremity angiography and therapeutic angioplasty after sub selective imaging on the left 
but not on the right side. There was filming of the right lower extremity but with Iliac artery placement of the 
catheter on the right. No sub-selective angiography on the right was performed. Thus, a unilateral left sub-selective angiogram was documented. 
 
We looked at this coder's review, the file, and Medicare rules. The billed code was for a bilateral service, but 
only a unilateral service was documented. 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 
radiological supervision services (procedure code 75716) provided to the enrollee on July 22, 2021.