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

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring services provided May 4, 2020.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring services. You say that you are asking for a timely filing exception as the billing company just did not file the claims in a timely manner. The Plan denied your request. The Plan says the claim was filed past the timely filing limitation.
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 the continuous intraoperative neurophysiology monitoring services was not filed until June 17, 2021. 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 continuous intraoperative neurophysiology monitoring services provided May 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic (CPT code 96401) provided to the enrollee on June 3, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the injection itself is a patient self-administered substance/medication and is denied as a
Medicare Part D service.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. The enrollee received a subcutaneous injection of Nucala, administration of which remains
denied as not chemotherapy. The injection itself is a patient self-administered substance/medication and is
denied as a Medicare Part D service. Therefore, we decided that the Plan does not have to pay for
chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic (CPT code 96401)
provided to the enrollee on June 3, 2021.
Benefits for the service 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76942) provided on July 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, we have confirmed that code 76942 is a column II code to column I code 76770. This claim has
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (76942)
provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the end stage renal disease (ESRD) services provided from February 1, 2021 to February 26, 2021.

You asked the Plan to pay for the end stage renal disease services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable as billed.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Review of the file shows that the modifier billed with these services is invalid. Therefore, we decided that the Plan does not have to pay for the end stage renal disease (ESRD) services provided from February 1, 2021 to February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Genesight testing provided on September 16, 2020.
You asked the Plan to pay for the Genesight testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that performing providers are required to acquire and retain records of the drugs under consideration for use or in use by the ordering physician that necessitate the use of ordered test.
We looked at the file and Medicare rules. Review of the file shows that the order for this testing was not signed by the ordering provider and is dated September 18, 2020, which is after the date of service of the services at issue. Based on this information, we decided that Medicare rules for coverage of the Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for the Genesight testing provided on September 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.

You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied your request. The Plan says the information fails to indicate the enrollee meets the requirements.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.

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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. She is taking Gabapentin, Methocarbimol, Naproxen, Percocet and Xtampza for pain. There is no documentation of prior diagnostic medial branch blocks. Therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for removal of connective tissue of palm and
release of finger (26123) provided by an OON provider on February 19, 2021.
You asked the Plan to waive the coinsurance for hand and finger surgery. You say that you found out after
receiving a bill that your insurance plan does not work with the provider you received services from. You also
say a public relations representative told you that you must pay regardless of the outcome of the operation. You
say your hand still hurts and your finger does not work. You feel you should not be liable. The Plan denied
your request. The Plan says the original claim was calculated at $4,697.09. The claim was later reviewed, and it
was determined that the original allowed amount was incorrect. The Plan then adjusted the allowed amount to
$2,150.72, resulting in a recalculated coinsurance. The Plan says the cost-share was applied 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 50%
coinsurance for Outpatient Surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a cost-share of $1,075.36 for hand and finger surgery ($2,150.72 Allowed
Amount  50% coinsurance = $1,075.36). Hand and finger surgery falls within the Outpatient Surgery 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 coinsurance for removal of connective tissue of palm and
release of finger (26123) provided by an OON provider on February 19, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (52332) provided July 22, 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 number of units billed exceeds the allowed amount.

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 52332 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 (52332) provided July 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on February 8, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.
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 99291 is not supported in the medical record. The documentation submitted do not
include a critical care progress note for the billed date of service of February 8, 2021; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on February 8, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210), bone graft
(21215), and periodontal mucosal grafting (41870) provided on January 6, 2021.
You asked the Plan to reimburse you for the dental services. You say that you had a health emergency
regarding and infection in your mouth. You say that you were advised the services would be covered by your
health plan instead of your dental plan. You say that you feel you were misled regarding the coverage for these
services. You also say that you should be reimbursed the full amount for these services. The Plan denied your
request. The Plan says the services you received are dental in nature. The Plan says that routine dental services
are not covered under your medical benefit. The Plan also says that the surgical extraction, bone graft, and
periodontal mucosal grafting are not listed as covered routine dental services.
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 surgical extraction, bone graft, and
periodontal mucosal grafting are not among those covered under this benefit. The services you are asking the
Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the
structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.
Additionally, the record shows that you did not contact the plan prior to the date of service to verify benefits for
the codes provided. Therefore, we decided that the Plan does not have to reimburse you for the surgical
extraction (D7210), bone graft (21215), and periodontal mucosal grafting (41870) provided on January 6, 2021.
Your complaint about being misled by a plan representative 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on June 4, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the surgical payment.  The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery.   We looked at the file and Medicare rules. Payment for this service is included in the global surgical package for the surgery performed on June 3, 2021. This procedure has a 90-day global period. Separate payment cannot be made for the requested service. 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 provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical osteogenesis stimulator.

You asked the Plan to pre-approve the requested services. You say that the enrollee requires the device for proper healing in the correct post-surgical time frame. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that osteogenesis stimulators are only covered under certain medical indications.

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 requested services. Our physician reviewer found that the enrollee is being treated for fusion of spine, cervical region, arthrodesis status. He has a documented history of a C5 and C6 surgery and was scheduled to undergo C4 and C5 anterior cervical discectomy and fusion. However, detailed documentation is not evident that the previous procedure at C5 and C6 was a fusion procedure. Additionally, the documentation is not evident that the enrollee has undergone the C4 and C5 procedure. The C5 and C6 procedure was noted to have been performed in August 2021.

There has not been 9 months since the surgery to meet the guideline of a failed spinal fusion. The documentation indicated the C4 and C5 anterior cervical discectomy and fusion that was scheduled for October 2021, was cancelled due to a denial. This does not meet the criterion for following a multilevel spinal fusion surgery. Additionally, detailed documentation is not evident regarding any previous failed fusion at the same site. Therefore, the records do not show that the enrollee meets the coverage criteria for the requested spinal electrical osteogenesis stimulator.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical osteogenesis stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic radiographic imaging (D0330), bitewings (D0274), and periodontal scaling and rooting (D4342) provided by an out-of-network provider on July 2, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, panoramic radiographic imaging, bitewings, and periodontal scaling and rooting. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says these services were provided by an out-of-network provider. The Plan says that D4342 is not a covered benefit.

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, D4342 is not among those covered under this benefit. The cost sharing amount for an out-of-network provider is 100% for the enrollee. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic radiographic imaging (D0330), bitewings (D0274), and periodontal scaling and rooting (D4342) provided by an out-of-network provider on July 2, 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 IRF care is medically reasonable and necessary for the enrollee's condition. 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 on review of the available records the enrollee with left below knee amputation and right femur fracture who is medically stable and does not meet Medicare coverage criteria for an IRF admission. With his current medical stability, and no complex medical problems, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. He has no acute rehab nursing needs. He does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. He is not fitted with a prosthesis. His mobility is at wheelchair level till the fracture heals. His rehab needs can be addressed just as well in a skilled nursing facility and acute rehab with a short stay will not allow him to gain a level of function that is adequate to go home and he will not benefit from IRF stay. IRF admission is not medically necessary. Document does not support the necessity for admission. While the enrollee may benefit from continued physical therapy and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as in an SNF. 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 pay for SelectMDx testing (81479) provided on July 26, 2021.
You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that SelectMDx has been deemed investigational.
Code 81479 is not considered medically necessary when used for SelectMDx.
We looked at the file and Medicare rules. The testing at issue is not considered medically necessary and is
therefore not covered. Based on this information, we decided that Medicare rules for coverage of SelectMDx
testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing
(81479) provided on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 13, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation submitted supports one unit of code 71045, which was previously approved and paid by the Plan. There is no additional documentation supporting an additional study which was billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for bupivacaine hydrochloride, 30ML injection (CPT code
S0020) provided to the enrollee on January 13, 2021.
You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is 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.
CPT code S0020 is assigned a status code I which is not valid for Medicare purposes. As the claim was billed
with a CPT code which is invalid for usage with Medicare; we find that Medicare rule for payment of this
claim has not been met. The Plan states if the provider determines that a billing error occurred during the initial
submission of the denied claim, the Plan will accept a submission of a corrected claim to consider services for
payment. Based on this information, we decided that Medicare rules for coverage of the injection have not been
met. Therefore, we decided that the Plan does not have to pay for bupivacaine hydrochloride, 30ML injection
(CPT code S0020) provided to the enrollee on January 13, 2021