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

We decided that the Plan does not have to pay for the services (procedure codes 36005, 93770) provided to the enrollee on June 9, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT 93770 has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 

An edit exists between CPT 36005 and 36012. Modifiers would be allowed with this code pair; however, an appropriate modifier was not used in this case. 

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 (procedure codes 36005, 93770) provided to the enrollee on June 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says a step therapy exception cannot be granted.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not contain documentation of trial and failure of Infed and Venofer. The documentation does not support that Infed and Venofer would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and comprehensive oral evaluation - new or established patient (D0150) provided October 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the complete series of x-rays and comprehensive oral exam. You say that the Plan and the provider gave you incorrect information indicating the services would be covered. The Plan denied your request. The Plan says these services are not covered when provided OON.
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. The Plan covers the complete series of x-rays and comprehensive oral exam when the services are provided in-network.
We looked at the file and Medicare rules. In this case the services were provided out-of-network. Based on this information, we decided that the Plan's rules for coverage of the complete series of x-rays and comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and comprehensive oral evaluation - new or established patient (D0150) provided October 13, 2021, by an out-of-network (OON) provider.
Your complaint about potentially receiving misinformation from 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on August 25, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
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 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records.
Our reviewer found the documentation submitted does not indicate that the enrollee was monitored by an independent trained observer during moderate sedation for the cardiac catheterization. According to coding guidelines, CPT code 99153 is used "for the reimbursement of the additional practice expense of the moderate sedation service only. There are no work RVUs assigned to this code. Since a physician would not be expected to incur any practice expenses when providing a service in a facility setting, codes that reimburse for the practice expense only, are not reimbursable to the physician when the service is performed in a facility setting." 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 services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan of an upper extremity joint (73221) provided on July 1, 2021, by an out-of-network provider.
You asked the Plan to pay for an MRI scan of an upper extremity joint. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
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 a magnetic resonance imaging (MRI) scan of an upper extremity joint (73221) provided on July 1, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99053) provided on July 25, 2021.
You asked the Plan to pay for the services. You say that fafasdffsd The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99053 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 99053. 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 (99053) provided on July 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on September 9, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not 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, we have confirmed that code 72050 is a column II code to column I code 72082. 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 radiology services provided to the enrollee on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 15, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the use of modifier -59 was not supported in this case.
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 35372 is "Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records provided indicate that procedure 35355 was performed on April 5, 2021. CPT 35372-59 is included in CPT 35355. The medical records provided do not include sufficient documentation to validate that 35372 59 was performed as a distinct, separate service, therefore the use of a -59 modifier to unbundle 35372 from 35355 is not appropriate.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the facility payment.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Erleada tablet.
You asked the Plan to pre-approve Erleada. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered oral cancer drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B because it does not have the same active ingredients and is used for the same indications as any non-oral anti-cancer chemotherapeutic agent. Therefore, we decided that the Plan does not have to pre-approve treatment with Erleada tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 resin-based composites, 4 or more surfaces or involving incisal angle (anterior), (D2335) provided on March 31, 2021.
You asked the Plan to pay for the resin-based composites. You say that you received prior authorization for these services. You say that you would not have had these services done if they had not been approved. You also say that these should be reprocessed. The Plan denied your request. The Plan says resin-based composite, 4 or more surfaces or involving incisal angle (anterior), is not listed as covered.
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 resin-based composite, 4 or more surfaces or involving incisal angle (anterior), are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 3 resin-based composites, 4 or more surfaces or involving incisal angle (anterior), (D2335) provided on March 31, 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. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for a left femoral neck fracture. He is ambulating with minimal assist. The documentation does not support that the enrollee in this case requires at least 3 hours a day.
While there is a reasonable expectation that the enrollee would be able to fully participate in an intensive rehabilitation therapy program, the documentation supports that his needs may be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that the clinical records provided support the need for the requested MRI. The Plan denied your request. The Plan says the requested MRI is not medically necessary.
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 the MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found a lumbar x-ray revealed severe disk degeneration and arthritic changes. Review of the recent notes did not reveal a physical examination by the treating physician within 3 months of this request (no evidence of red flag diagnosis), and there was no report of a recent failed six-week trial of conservative treatments to justify advanced imaging at this time.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 19, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell, and your wife called the fire department for assistance to help you get up. You say the ambulance assisted you and checked your vitals and you feel that you should not be liable for charges because you did not ask for or need the ambulance. The Plan denied your request. The Plan says the ambulance service is a transport benefit, and it is only payable when you're transported to a hospital. If an ambulance is called and you received care, but decide not to be transported to a hospital, we do not cover those services.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 3, 2021, to August 1, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says there were no skilled therapy or skilled nursing service needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 3, 2021, to August 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided October 17, 2021.
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Attached reports to support the level of service. The Plan denied your request. The Plan says duplicate of a claim processed. This service was previously approved and paid.
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. We find that CPT code 71045 is not supported in the medical record. Specifically, the records support two chest x-rays being performed on this date of service. The first chest x-ray was performed at 6:18 pm and the second was performed at 8:56 pm. One claim paid on October 27, 2021 and the other claim paid on October 31, 2021. The submitted documentation does not support any additional chest x-rays. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71045) provided October 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to waive the copayments for psychiatric diagnostic evaluations provided on October 20, 2021.
You asked the Plan to waive the copayments for psychiatric diagnostic evaluations. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We did not receive the correct Evidence of Coverage from the Plan. We are unable to determine the correct cost sharing amount for these services. Therefore, we decided that the Plan has to waive the copayments for psychiatric diagnostic evaluations provided on October 20, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions (D7320) and removal of lateral exostosis (D7471).
You asked the Plan to pre-approve alveoloplasty not in conjunction with extractions and removal of lateral exostosis. You say that you need this procedure to receive your dentures. You also say you do not have bottom teeth at the moment. The Plan denied your request. The Plan says the requested dental procedures are not covered under your benefit 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 pre-approve alveoloplasty not in conjunction with extractions (D7320) and removal of lateral exostosis (D7471).