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

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 11,
2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of
service. 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 code.
We looked at the file and the rules. We find that CPT code 70450 was billed with code 70496. CPT code 70450
may be eligible for payment when billed with this code pair. The claim provided does not show that a modifier
suitable for payment was billed. Based on this information, we decided that Medicare rules for coverage have
not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan
provided on July 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the
enrollee. The Plan denied your request. The Plan says that unproven and not medically necessary procedures
are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on August 11, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you are a specialized laboratory that performs drug
monitoring. You say the service was medically necessary. The Plan denied your request. The Plan says no prior
authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the drug testing provided on August 11, 2021, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on August 3, 2021.

You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the service is bundled to another service billed on the same day.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that CPT code 76700 was billed with code 93976. CPT code 76700 may be eligible for payment when billed with this code pair. However, the claim provided does not indicate the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a vitrectomy (face down) chair provided on June 15, 2021.  You asked the Plan to pay for this equipment. You say that your physician prescribed this equiment for use after eye surgery. The Plan denied your request. The Plan says this equipment is preventative in nature and is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A vitrectomy chair is preventative and does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pay for a vitrectomy (face down) chair provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0367) and three additional intraoral periapical x-rays (D0230 x3) provided on July 15, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation and additional intraoral periapical x-rays. You say that the dental office advised that you have a $1,000 allowance to use toward dental services. You also say that you cannot pay this bill, nor should there be a bill at all. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not a covered benefit. The Plan also say that your benefits for the additional intraoral periapical x-rays have been satisfied and the frequency limitation has been exceeded.
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, cone beam CT capture and interpretation (D0367) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received four additional intraoral periapical x-rays (D0230 x4), one of which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0367) and three additional intraoral periapical x-rays (D0230 x3) provided on July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on July 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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, 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 services (70450) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on August 10, 2021.

You asked the Plan to pay for the complete maxillary denture. You say that you would like this claim to be reconsidered for coverage. 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 complete maxillary denture (D5110) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331), and consultation (D9310), provided on April 1, 2021.

You asked the Plan to pay for the consultation and treatment of root canal obstruction. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.

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 treatment of root canal obstruction (D3331), and consultation (D9310), provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the enrollee.  You asked the Plan to pre-approve the services. You say that the enrollee would like this device instead of having to travel to outpatient therapy during the current pandemic. The Plan denied your request. The Plan says the swelling does not extend to the truncal region.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee only has leg edema but no truncal edema. The device is only indicated for edema extending into the trunk. The review indicates that the enrollee does not have lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a trial and failure of the standard pump.  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 pre-approve a pneumatic compression device (E0652) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided May 26,
2021.
You asked the Plan to pay for the radiology services. You say that the claim denied in error as a duplicate.
Please review and process for payment. The Plan denied your request. The Plan says duplicate of a claim
processed, or to be processed, as a crossover claim. There is no documentation supporting the services being
performed.
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 show that this
service was paid on check dated 06/09/2021. Based on this information, we decided that Medicare rules for
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay
for the radiologic examination, chest (71045) provided May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (19301, 14302, 14301, 38525) provided August 27, 2020.
You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider type billed is ineligible for payment for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (19301, 14302, 14301, 38525) provided August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from December 10,
2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you need additional
inpatient psychiatric care. The Plan denied your request. The Plan says you have been approved for inpatient
psychiatric care from November 26, 2021, to December 9, 2021. The Plan has made a reasonable and diligent
effort to obtain necessary medical records from the provider to substantiate medical necessity of continued
care, but no records have been provided.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. The rules also say that for Medicare to consider coverage and payment for
any item or service, the information submitted by the supplier or provider must corroborate the documentation
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of continued inpatient psychiatric care have not been met. Specifically, no medical records were
submitted for review to substantiate whether additional psychiatric care at the inpatient level is medically
necessary. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric
care from December 10, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the appropriate level of care for this enrollee, and the transfer is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a laparoscopy provided from May 18,
2021, to May 20, 2021.
You asked the Plan to waive the coinsurance for a laparoscopy. You say that you disagree with the high
surgical charges. The Plan denied your request. The Plan says the claims were processed correctly and you are
being charged the correct 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received a laparoscopy at an outpatient hospital facility from May 18, 2021, to May 20, 2021. Therefore,
you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $4,588.79 and
20% of that is $917.76.
You have been asked to pay the total coinsurance amount of $917.76 for a laparoscopy. A laparoscopy falls
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers 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 a laparoscopy provided
from May 18, 2021, to May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 23, 2020, to August 28, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that you were not aware what insurance the enrollee had until after the services were rendered. You also say that the services provided were medically necessary. The Plan denied your request. The Plan says that the inpatient level of care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 23, 2020, to August 28, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on July 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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, 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 services (70450) provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolotherapy provided on January 27, 2021.
You asked the Plan to pay for the prolotherapy. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that prolotherapy is not a covered service. We looked at the file and Medicare rules. Per LCD L35010, the requested prolotherapy is not covered. Based on this information, we decided that Medicare rules for coverage of the prolotherapy have not been met. Therefore, we decided that the Plan does not have to pay for the prolotherapy provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 27,
2020.
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 records do not support the services 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 the various denied CPT codes are not supported in the medical record. Specifically, the place of
service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The
claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of
a doctor's office (POS 11). 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 laboratory services
provided to the enrollee on August 27, 2020.