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

 We decided that the Plan does not have to pre-approve bariatric surgery.  You asked the Plan to pre-approve bariatric surgery. You say that you attached medical records going back as far as you could. The Plan denied your request. The Plan says the records do not show that you have participated in an intensive weight loss program. The Plan also says the records do not contain an evaluation from a bariatric surgeon, mental health provider or registered dietician.  The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have:   (1) a body mass index (BMI) of greater than or equal to 35;   (2) at least one co-morbidity related to obesity; and  (3) been unsuccessful with medical treatment for obesity.    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 bariatric surgery. Our reviewer says that the coverage criteria are not satisfied. Our physician reviewer found that the records provided do not address the coverage criteria requirements and the requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve bariatric surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the fillings (D2330) provided on October 25, 2021.  You asked the Plan to pay an additional amount for the fillings. You say that the services should be covered. The Plan denied your request. The Plan says there is a 50% coinsurance for fillings when you receive them in network. The Plan also says that the claim was processed correctly.  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 and fillings are listed as covered, there is a 50% coinsurance when you receive them in network. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the fillings (D2330) provided on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the aflibercept injection (J0178) provided October 7, 2021.  You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you were unaware that you would be responsible for 20% coinsurance. The Plan denied your request. The Plan says the cost-sharing was applied correctly up to your maximum out-of-pocket 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 20% coinsurance for Medicare Part B prescription drugs up to the out-of-pocket maximum of $2,000.   You have been asked to pay 20% coinsurance of the contracted amount ($3,671.77) for this injection is $734.35, however you had only $487.49 remaining in your out-of-pocket amount at the time this service was processed. Therefore, your cost-share for the aflibercept injection was applied correctly as $487.49. The aflibercept injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the aflibercept injection (J0178) provided October 7, 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 September 20, 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 procedure code 70544 is 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 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 September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942).  You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental.  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 pay for the ultrasonic guidance for needle placement. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure to the lumbar paraspinal/myofacial area does not typically require ultrasound guidance as there is no anatomical high risk for misplacement and the notes did not reveal special circumstances to be an exceptional case. Evidence does not support the use of ultrasound guidance to the lumbar muscles/myofascia.  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 ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) provided on July 16, 2021.  You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says two evaluation and management services were reported by the same provider on the same date of service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.   We find that CPT code 99213 is not supported in the medical record. Specifically, this evaluation and management service was billed twice on the same day by the same provider. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for transpedicular approach services (63056) provided on April 29, 2021.  You asked the Plan to pay for transpedicular approach services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says code 63056 is not supported in the medical 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 63056 is transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc).  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 transpedicular approach services. Our reviewer says that the documentation does not support the claim as billed. Our reviewer found the operative report does not describe a transpedicular approach for disk herniation. To cite the operative report: "Once exposed partial resection of spinous process of L2, L3, L4 and L5 was performed using high-speed bur. Upon completion of the decompression a Murphy probe could be freely passed into the neuroforament bilaterally at L2-3, L3-4, L5-S1.  The deep subcutaneous tissue closed with 0 Vicryl. The superficial subcutaneous tissue closed with 2-0 Vycryl." Per the National Correct Coding Initiative Policy Manual a transpedicular approach is a surgical procedure to treat throacic disc herniation. 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 transpedicular approach services have not been met. Therefore, we decided that the Plan does not have to pay for transpedicular approach services (63056) provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient clinic visit and trigger point injection provided on August 23, 2021.  You asked the Plan to waive the copayment for the outpatient clinic visit and trigger point injection. You say that you were told this was an office visit when performed and all you would owe is $45. You say that this was an office visit done at the doctor's office not an outpatient hospital procedure. The Plan denied your request. The Plan says the copayment applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $289 copayment for in-network outpatient hospital services.    You have been asked to pay a $289 copayment for the outpatient clinic visit and trigger point injection. The outpatient clinic visit and trigger point injection fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the services were billed by the hospital. 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 outpatient clinic visit and trigger point injection provided on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head (70450) provided on September 12, 2021.  You asked the Plan to pay for the CT scan services. You say that this claim denied as a duplicate in error. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare rules to bypass the edit.  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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head (70450) provided on September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on February 8, 2021.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the scanning computerized ophthalmic diagnostic imaging (92134) rendered by the out-of-network (OON) provider on June 14, 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 office visit (99214) and the scanning computerized ophthalmic diagnostic imaging (92134) rendered by the out-of-network (OON) provider on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring (95251) provided on August 26, 2021.  You asked the Plan to pay for the ambulatory continuous glucose monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate modifier.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 95251 is not supported in the record. Specifically, CPT code 95251 was billed with modifier 95 to indicate that this was a telehealth service. CPT code 95251 is not on the list of approved telehealth service CPT codes. Based on this information, we decided that Medicare rules for coverage of the ambulatory continuous glucose monitoring have not been met.      Therefore, we decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring (95251) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided from September 14, 2021, to September 15, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that the services billed incorrectly for an outpatient when you were an inpatient. The Plan denied your request. The Plan says there was never a written order to admit the enrollee as an inpatient to the hospital from the provider. The proper copayment was applied.  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 $35 copayment for each specialist visit, including outpatient clinic visits. Since there was two days charged for a specialist visit the total copayment for both days was $70 ($35 x 2 days).    You have been asked to pay a $70 copayment for a specialist visit. Specialist visits falls within the Outpatient hospital services 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 a specialist visit provided from September 14, 2021, to September 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 1, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this claim was submitted with procedure code A0998 which is a valid code on this date of service for the ambulance response and treatment with no transport. You also say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says Original Medicare does not cover ambulance treatment without transport. The Plan also says that according to the trip report the enrollee refused transportation to the hospital.  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 June 1, 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 the ambulance response and treatment with no transport (A0998) provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspiration.  You asked the Plan to pre-approve bone marrow aspiration. You say that the enrollee is in a lot of pain and this needs to be addressed. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this is helpful for treatment of the enrollee's 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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental. More research is needed to show its 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine (E0601) provided on July 14, 2021.  You asked the Plan to pay for a CPAP machine. You say that the item at issue was a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.  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 a continuous positive airway pressure (CPAP) machine (E0601) provided on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you would like to return to being independent. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You have debility from seizures and are medically stable. With your comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehab nursing needs noted in the record. At the current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical and occupation therapy, your rehab needs can be safely met in an alternate and lower intensity setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oxygen and oxygen supplies rendered on August 23, 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 covered.  The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded.  We looked at the file and Medicare rules. Billed procedure code A0422 (ambulance oxygen and oxygen supplies) has a status indicator of X and is excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the oxygen and oxygen supplies rendered on August 23, 2021.