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

 We decided that the Plan does not have to pre-approve Intracept procedure.  You asked the Plan to pre-approve Intracept procedure. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says clinical value and effectiveness not shown in peer reviewed literature.  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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided on April 7, 2021.  You asked the Plan to pay for the lab services. You say that you have provided medical records to support payment of this claim. The Plan denied your request. The Plan says you billed this lab service with the wrong place of service.  The Plan must follow Medicare rules. Medicare rules say that when billing for lab services, the place of service code reported must be based on the physical location of the patient at the time the specimen was collected. In this case, you billed with place of service 81, meaning an independent laboratory. However, the records indicate that the specimen was taken from the patient by the patient's doctor several days prior to the lab services being provided.  Therefore, the place of service of 81 does not appear to be correct.       We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel (81455) provided on August 2, 2021.  You asked the Plan to pay for code 81455. 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.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel (81455) provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a nerve procedure called Peripheral Nerve Stimulator (PNS) using a STIMQ device.  You asked the Plan to pre-approve a nerve procedure called Peripheral Nerve Stimulator (PNS) using a STIMQ device. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is not covered for the members 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 a nerve procedure called Peripheral Nerve Stimulator (PNS) using a STIMQ device. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational therapy for shoulder pain which is not related to amputation or sympathetic dysfunction.   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 nerve procedure called Peripheral Nerve Stimulator (PNS) using a STIMQ device have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve procedure called Peripheral Nerve Stimulator (PNS) using a STIMQ device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle skin graft (15734) provided on July 22, 2021.

You asked the Plan to pay for the muscle skin graft. 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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk. 

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 muscle skin graft. Our reviewer says that CPT code 15734 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not describe a muscle, myocutaneous, or fasciocutaneous flap per NCCI guidelines to include repair of a defect area using muscle, muscle and skin, or fasciocutaneous and rotating flap from the donor area to the site to be repaired, and sutured. Therefore this procedure cannot be confirmed. 

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 muscle skin graft have not been met. Therefore, we decided that the Plan does not have to pay for the muscle skin graft (15734) provided on July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for 28 units of procedure code G0069.  You asked the Plan to pay for 28 units of procedure code G0069. You say that you have provided medical records to support payment. The Plan denied your request. The Plan says the medical records do not support the code 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 G0069 is professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.  We find that 28 units of CPT code G0069 are not supported in the medical record. Specifically, this code is to be billed in 15 minute increments.  According to the medical records, the infusion services lasted 6 hours and 20 minutes.  This total time divided by 15 minutes equals 26 units.   However, you have billed for 28 units.  There is no explanation from you as to why the additional units were billed. Based on this information, we decided that Medicare rules for coverage of 28 units of procedure code G0069 have not been met. Therefore, we decided that the Plan does not have to pay for 28 units of procedure code G0069.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the colorectal cancer screening (G0121) provided on June 23, 2021.  You asked the Plan to pay for the colorectal cancer screening. You say that you were requested to schedule a colonoscopy and were also told that you need to schedule one for next year if you had a condition. The Plan denied your request. The Plan says you have not met the medical necessity criteria for High Risk which is covered at a frequency of once every 10 years. The Plan also says that there is no clinical documentation to support the medical necessity of billing G0121 more frequently than once every 10 years.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.     We looked at the file and Medicare rules. The record shows that the Plan made multiple attempts to obtain records for this date of service, but no medical records were provided. Based on this information, we decided that Medicare rules for coverage of the colorectal cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for the colorectal cancer screening (G0121) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953), guided tissue regeneration - resorbable barrier, per site (D4266), and unspecified preventive procedure, by report (D1999) provided September 27, 2021.  You asked the Plan to pay for the bone replacement graft, guided tissue regeneration and unspecified preventative procedure. You say that these benefits should be covered. The Plan denied your request. The Plan says these services are 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 bone replacement graft for ridge preservation - per site (D7953), guided tissue regeneration - resorbable barrier, per site (D4266), and unspecified preventive procedure, by report (D1999) provided September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio screening (81439) provided on July 15, 2021.

You asked the Plan to pay for the hereditary cardio screening (81439). 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.

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. 

The test at issue in this appeal, the hereditary cardio screening (81439), was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardio screening (81439) provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a complete mandibular denture (D5120) provided by an out-of-network provider on September 14, 2021.  You asked the Plan to pay for a complete maxillary denture and a complete mandibular denture. You say that you should not have to pay for these services. The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered 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 when provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a complete mandibular denture (D5120) provided by an out-of-network provider on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cervical or vaginal cancer screening, pelvic and clinical breast examination (G0101) provided on January 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient services. You say that please reconsider attached claim for payment. You were under the impression that all gynecologic care and woman annual exams are covered without a referral. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the cervical or vaginal cancer screening, pelvic and clinical breast examination (G0101) provided on January 25, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and computed tomography (CT) scan of the abdomen and pelvis provided from October 25, 2020, to October 26, 2020.  You asked the Plan to waive the copayments for the ER visit and CT scan. You say that you were not billed for the emergency room visit, but you did already pay for the CT scan and medication. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit.  Your contract with the Plan also clearly says that you must pay a $275 copayment for advanced imaging services, such as CT scans, provided at an outpatient hospital.   You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care benefit category. You have also been asked to pay a $275 copayment for the CT scan. The CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for an emergency room (ER) visit and computed tomography (CT) scan of the abdomen and pelvis provided from October 25, 2020, to October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81404, 81442, 81479) provided June 8, 2021.  You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is non-covered.  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.  The test at issue in this appeal, a genetic cardiovascular screening test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81442, 81479) provided June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve orthopedic footwear.  You asked the Plan to pre-approve foot orthotics. You say that the enrollee has peroneal nerve palsy with stiff deformity. The Plan denied your request. The Plan says this item is excluded from coverage.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    The records do not show that the enrollee suffers from diabetic foot disease or an integral part of a brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and unspecified preventive procedure, by report (D1999) provided September 15, 2021.  You asked the Plan to pay for the dental consultation and unspecified preventative procedure. You say that you were not made aware there would be a charge for these services. The Plan denied your request. The Plan says these services are 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 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and unspecified preventive procedure, by report (D1999) provided September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (90867).  You asked the Plan to pay for the outpatient services. You say that you have tried every type of service to help you and you believe this service will help you tremendously. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (90867).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subarachnoid opioid injection provided on October 25, 2021.  You asked the Plan to pay for the subarachnoid opioid injection. You say that this was denied due to the diagnosis not being appropriate for an epidural steroid injection. You state that this was not the services rendered. This injection was a subarachnoid opioid injection which is supported as effective for the enrollee's condition. The Plan denied your request. The Plan says no medical records were submitted to support that this injection was medically necessary.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   In this case, no medical records were submitted for review to confirm what services were rendered nor that criteria have been met. Therefore, we decided that the Plan does not have to pay for the subarachnoid opioid injection provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Advance Monofocal Accommodating or Extended Depth-of-Field presbyopia-correcting Intraocular Lenses (IOL).  You asked the Plan to pre-approve Advance Monofocal Accommodating or Extended Depth-of-Field presbyopia-correcting Intraocular Lenses (IOL). You say that this is necessary for you. The Plan denied your request. The Plan says that Medicare doesn't cover implantable presbyopia-correcting (P-C) or astigmatism-correcting (A-C) intraocular lenses following cataract surgery.  The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL.   While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve Advance Monofocal Accommodating or Extended Depth-of-Field presbyopia-correcting Intraocular Lenses (IOL).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spinal cord injection (62320) provided on July 26, 2021.  You asked the Plan to pay for the spinal cord injection (62320). You say that the procedure billed is for subarachnoid injection therefore the policy of interlaminar epidural injections is not applicable. You say that subarachnoid opioids are very effective for decreasing pain and the service should be paid. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of the service.   The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal cord injection (62320) have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the spinal cord injection (62320) provided on July 26, 2021.