Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant (D6010) provided on June 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you do not agree with the denial. You say that 
you had a partner that received this service, and it was covered. You also say that your coverage includes 
prosthodontic benefits. The Plan denied your request. The Plan says endosteal implant is not listed as a covered 
service. 
 
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 endosteal implant is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endosteal 
implant (D6010) provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head 
rendered on June 16, 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 separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70544 (MRA of the head) and 70551 (magnetic resonance 
imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with 
column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the 
head rendered on June 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your needs can be met with home exercise.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 therapy is not generally accepted as effective therapy for your condition beyond what was approved by the plan. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist.
You have been instructed in and are compliant in a home exercise program. The specialized skill of a qualified therapist is not required to deliver a program to maintain your current condition or to prevent or slow deterioration. 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 additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on 
April 7, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 80307 and G0483 are not supported in the record. Specifically, the claim was 
submitted with the laboratory POS code, but the record indicates that the member's face-to-face service was 
rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the 
drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing services (80307 and G0483) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on May 25, 2021 by an out-of-network (OON) provider.
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 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 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 home visit provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that you were never told this would be sent out-of-network. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and prior authorization was denied as this testing was available at an in-network lab.
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 laboratory testing provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology (thyroid) mRNA gene expression analysis
provided on May 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the oncology (thyroid) mRNA gene expression analysis. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are
not a covered benefit.
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 oncology (thyroid) mRNA gene expression
analysis provided on May 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks.
You asked the Plan to pre-approve facet blocks. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet specific coverage criteria.
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 facet blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation as to why radiofrequency ablation is not medically appropriate. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for new patient outpatient office visit (99202) and radiological 
examination, spine (72084) provided June 15, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that the Plan did not pay your bill for new 
patient x-rays and you would like to appeal. The Plan denied your request. The Plan says these services are not 
covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for new patient outpatient office visit (99202) and radiological examination, 
spine (72084) provided June 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational
therapist on May 11, 2021.
You asked the Plan to pay for the occupational therapy services. The Plan denied your request. The Plan says
we cannot confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as
services incident to a physician/non-physician practitioner's service must meet all incident requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided
by an occupational therapist on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided June 15, 2021. 
 
You asked the Plan to pay for the office visit. You say that you have been denied coverage for new patient 
consultation. You have been told by a Plan representative that this is not covered while treatments are. The 
Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) provided June 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy services coded 31652, 31629, 31628,
31624, and 31627 provided on January 18, 2021.
You asked the Plan to pay for the bronchoscopy 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 31652, 31629, 31628, 31624, and 31627 are not supported in the medical record.
Specifically, the submitted medical records do not include detailed procedure note to support that
bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial
ultrasound (EBUS) guided transtracheal and/or transbronchial sampling, one or two mediastinal and/or hilar
lymph node stations or structures was performed; therefore, code 31652 cannot be verified.
The submitted medical records do not include detailed procedure note to support that bronchoscopy, rigid or
flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy,
trachea, main stem and/or lobar bronchus was performed; therefore, code 31629 cannot be verified.
The submitted medical records do not include detailed procedure note to support that bronchoscopy, rigid or
flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy, single lobe was
performed; therefore, code 31628 cannot be verified.
The submitted medical records do not include detailed procedure note to support that bronchoscopy, rigid or
flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage was performed;
therefore, code 31624 cannot be verified.
Code 31627 is an add-on code that requires a primary code. Since the primary code is not present, this code
cannot be separately payable.
Based on this information, we decided that Medicare rules for coverage of the bronchoscopy services have not
been met. Therefore, we decided that the Plan does not have to pay for the bronchoscopy services coded 31652,
31629, 31628, 31624, and 31627 provided on January 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on February 
16, 2021 to March 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF care. You say that the service was medically necessary. The Plan denied 
your request. The Plan says prior authorization must be obtained prior to non-emergent services obtained by an 
out-of-network provider. 
 
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 skilled nursing facility (SNF) care, provided 
on February 16, 2021 to March 9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81185, 81401, 81403, 81404,
81405, 81406, and 81479, provided on April 14, 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 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.
We find that CPT codes 81185, 81401, 81403, 81404, 81405, 81406, and 81479 are not supported in the
medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of
the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim
history indicates that the specimen was obtained in an Office place of service 11. 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 81185, 81401, 81403, 81404, 81405,
81406, and 81479, provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2021 by a non-participating provider.
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 were rendered by a non-participating 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 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 laboratory services provided on May 12, 2021 by a non-participating provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the therapy in appeal is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The therapy appears repetitive, and the enrollee should be able to transition to an independent home exercise program at this point. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux (J9055). 
 
You asked the Plan to pre-approve Erbitux. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Erbitux. Our reviewer says that the 
requested Erbitux is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis salivary gland adenocarcinoma. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do 
not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Erbitux (J9055).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on April 16, 2021 by an out-of-
network (OON) provider. 
 
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 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 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 eye exam provided on April 16, 2021 by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99336) provided on January 27, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services obtained by 
an out-of-network provider.
 
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 home visit (99336) provided on January 27, 
2021, by an OON provider.