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

We decided that the Plan does not have to pre-approve Puros allograft services.
You asked the Plan to pre-approve the requested services. You say that you need to have your quality of life
back. The Plan denied your request. The Plan says the clinical effectiveness in the setting of anterior cervical
spine fusion surgery has not been demonstrated.
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 requested services. Our physician
reviewer found that the requested service is considered experimental. More research is needed to show safety
and efficacy of the bone graft material in spine surgery. Therefore, the requested service is 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 Puros allograft services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 88377, 88368, and 88189 provided on April 21, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 codes
88377, 88368, and 88189 for the laboratory services has a bundled relationship with codes 81450 and G0452
and cannot be paid as billed. This code cannot be paid as a separate line item. 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
laboratory services coded 88377, 88368, and 88189 provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency anesthesia (99140) provided on January 23, 2021.
You asked the Plan to pay for emergency anesthesia. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separate payable.
The Plan must follow Medicare rules.
Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99140 has a status indicator of B. Payment for this service is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of emergency anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for emergency anesthesia (99140) provided on January 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tenodesis of long tendon of biceps provided on March 16, 2021.

You asked the Plan to pay for the tenodesis of long tendon of biceps. 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 23430 is tenodesis of long tendon of biceps. 

We find that CPT code 23430 is not supported in the medical record. Specifically, the operative report did not include documentation of a tenodesis of the long tendon of the biceps; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the tenodesis of long tendon of biceps have not been met. Therefore, we decided that the Plan does not have to pay for the tenodesis of long tendon of biceps provided on March 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography (75716) provided on April 20, 2021. 
 
You asked the Plan to pay for the angiography. You say that you would like reconsideration because the 
National Correct Coding Initiative edit is resolved by billing modifier 59. The Plan denied your request. The 
Plan says the documentation 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 75716 is angiography, extremity, bilateral, radiologica l 
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 angiography. Our reviewer says that CPT code 75716
does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does 
not support CPT 75716 as a separate procedure.  Therefore, CPT 75716 would be inclusive to CPT 37225. 
 
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 angiography have not been met. Therefore, we decided that the Plan does 
not have to pay for the angiography (75716) provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an off-the-shelf diabetic inlay shoe (A5500) and a
multiple density insert (A5512).

You asked the Plan to pre-approve an off-the-shelf diabetic inlay shoe and a multiple density insert. You say
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says
medical necessity rules for the requested items have not been met.

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 an off-the-shelf diabetic inlay shoe and
a multiple density insert. Our reviewer says that the requested items are not considered medically reasonable
and necessary in this case. Our physician reviewer found that, according to the enclosed progress notes, it does
not appear that the enrollee meets the coverage criteria for the requested items.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an off-the-shelf diabetic inlay shoe and a multiple density insert have not been
met. Therefore, we decided that the Plan does not have to pre-approve an off-the-shelf diabetic inlay shoe
(A5500) and a multiple density insert (A5512).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the enrollee has an iron
deficiency and anemia. The enrollee is losing blood and needs treatment. The Plan denied your request. The
Plan says the enrollee does not meet the requirements for approval.
The Plan must follow Medicare rules. Medicare rules say that use of wireless capsule endoscopy should not be
used in patients with a cardiac pacemaker, or other implanted electromagnetic device.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a wireless capsule endoscopy have not been met. Specifically, the medical records show that the
enrollee has a pacemaker. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule
endoscopy (91110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0295) half rails (E0305) and innerspring mattress (E0271).

You asked the Plan to pre-approve the hospital bed rails and mattress. You say that the enrollee may benefit from a hospital bed as the enrollee needs to be elevated more than 30 degrees to breath more comfortably due
to heart disease. The Plan denied your request. The Plan says the enrollee did not meet the Medicare criteria for coverage.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 

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 hospital bed rails and mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the patient meets all of the Medicare criteria for medical necessity for the requested semi-electric hospital bed. Although the patient does appear to meet criteria for a manual hospital bed, the prescribing provider's medical notes do not document that the patient requires frequent changes in body position or has the need for immediate changes in body position that is required for coverage of a semi-electric hospital bed. 

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 hospital bed rails and mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed (E0295) half rails (E0305) and innerspring mattress (E0271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81015, 87086, and 81003 provided on August 3, 2020.

You asked the Plan to pay for the laboratory 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. 

We find that CPT codes 81015, 87086, and 81003 are not supported in the medical record. Specifically, the documentation does not include a physician order for the laboratory services rendered. The documentation does not include supporting information on why the services were rendered. This means the documentation does not support the services billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81015, 87086, and 81003 provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on May 4, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the laboratory services rendered by the out-of-network (OON) provider on
May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pulmonary function test you received on April 2, 2021.
You asked the Plan to waive the copayment for the pulmonary function test. You say that you should not be charged for this service because this test was part of your annual wellness exam. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for diagnostic procedures and tests. You have been asked to pay a $20 copayment for the pulmonary function test. The services that are part of an annual wellness exam are limited to this needed to develop or update a personalized prevention plan based on your current health and risk factors. It does not include diagnostic procedures and tests. The pulmonary function test falls within the diagnostic procedures and tests 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 the pulmonary function test you received on April 2, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation services provided from
April 27, 2021 to April 29, 2021.
You asked the Plan to waive the copayment for the observation services. You say that you would like the plan
to reconsider their decision. The Plan denied your request. The Plan says the claim has been processed
correctly per your plan benefits.
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 $275
copayment for outpatient hospital observation.
You have been asked to pay a $275 copayment for the observation services. The observation services fall within the outpatient hospital observation 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 the observation services provided from April 27, 2021 to April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resonance imaging (MRI) of the lumbar spine 
(72148). 
 
You asked the Plan to pre-approve an MRI. You say that this is necessary because you are having neck surgery. 
The Plan denied your request. The Plan says you have not tried conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the submitted records do not include 
documentation of conservative measures. Physical therapy is needed before the requested MRI can be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular panel testing provided on April 6, 2021.

You asked the Plan to pay for the services provided. You say that the records support the services rendered. The Plan denied your request. The Plan says screening testing is not a Medicare benefit.

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. 

In this case, the records provided do not indicate the testing was ordered for a specific treatment strategy or diagnosis. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular panel testing provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for inpatient hospital services provided from February 13, 2021, through February 15, 2021, or for the specialist physician services provided on February 26, 2021.

You asked the Plan to waive the cost sharing for the hospital stay and physician services. You say that the hospital did not do their due diligence in gathering your insurance information to ensure they would be paid.

You say the charges should be written off. The Plan denied your request. The Plan says you have been asked to pay the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% coinsurance for out-of-network inpatient hospital services. Your contract also clearly says that you must pay $40 copayment for specialist services. 

You have been asked to pay $1,979.90, which is 40% of the allowed amount for the inpatient hospital services ($4,949.75 allowed amount x 40% coinsurance = $1,979.90). Inpatient hospital services fall within the Inpatient Hospital Care benefit category.

You have also been asked to pay $40 copayment for specialist services. Specialist services fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 cost sharing for inpatient hospital services provided from February 13, 2021, through February 15, 2021, or for the physician services provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive procedure (D9999) provided on April 26,
2021.
You asked the Plan to pay for the adjunctive procedure. You say that you cannot afford to pay for this service.
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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
adjunctive procedure (D9999) provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism-correcting intraocular lens (A-C IOL) provided November 24, 2020.

You asked the Plan to pay for the A-C IOL. You say that you were not aware you would pay extra for this service. The Plan denied your request. The Plan says this request is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. 

While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-correcting intraocular lens (A-C IOL) provided November 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on May 5, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.
We find that CPT code R0070 is not supported in the medical record. Specifically, this code is a technical component only code where it should be reported in a hospital setting. However, the documentation shows that the enrollee was not in a skilled nursing facility. Therefore, this code was billed with an inappropriate place of service. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on May 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
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 services provided to the enrollee.