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

 We decided that the Plan does not have to pay for the acupuncture services received on February 12, 2021.  You asked the Plan to pay for the acupuncture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation shows that you had pain, numbness, and coldness in your hands and feet and sought care from an acupuncturist. Acupuncture is only covered for chronic low back pain. This means you did not receive the acupuncture services for a covered indiciation. Therefore, we decided that the Plan does not have to pay for the acupuncture services received on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee needs relief from the injection because they are unable to do daily activities or work. The Plan denied your request. The Plan says the service is not necessary.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found testing for sacroiliac joint dysfunction are negative. The requested sacroiliac joint injection is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on July 30, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.   PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure code 97110) provided to the enrollee on March 17, 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 there is a more appropriate code to use 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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility."  

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 based on the medical records provided, G0157 is the more appropriate code to use in this case.  

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 therapy services (procedure code 97110) provided to the enrollee on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolonged outpatient service (99354) provided on February 25, 2021.  You asked the Plan to pay for the prolonged outpatient service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99354 was not billed with a required primary procedure code.  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 99354 is an add-on code and has not been billed with an appropriate primary procedure code. 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 prolonged outpatient service (99354) provided on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81001, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on September 3, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81001, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Parkinson Alzheimer Dementia Disease Gene Panel provided on August 28, 2020.  You asked the Plan to pay for the Parkinson Alzheimer Dementia Disease Gene Panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare does not cover this testing for screening purposes.  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 Parkinson Alzheimer Dementia Disease Gene Panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no indication that the member had a family history of a dementia syndrome that would prompt a need for genetic testing. A diagnosis of Alzheimer's (or other types of dementia) can often be made on clinical ground alone and do not require performance of genetic testing. Likewise, such testing is not readily consistent with the generally accepted standards of practice or care 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 Parkinson Alzheimer Dementia Disease Gene Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Parkinson Alzheimer Dementia Disease Gene Panel provided on August 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on June 5, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says there is no documentation of a consultation with the attending physician.  The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation.  We looked at the file and Medicare rules. There is on documentation in this record supporting consultation or attempt at consultation was performed with the patient's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90834) provided on June 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on September 20, 2021.  

You asked the Plan to pay for the ambulance service. You say that the emergency medical service (EMS) recommended that you not be transported to the hospital based on the current state of the local hospital's emergency room. You say that it was determined you rest comfortably until you could follow up with your family practitioner. You also say that this should be covered. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since no transport was provided there is not payable service.  

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 September 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The file shows that you told the EMS you did not want to be transported to the emergency department. The record shows that you had no intention of being transported. The record also shows that you signed a refusal of transport form. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physicians services (12001) provided March 24, 2021. 

You asked the Plan to pay for the physicians services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is not separately payable.
  
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 12001 is a column II code to column I code 24670. 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 physicians services (12001) provided March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81162, 81292, 81321) provided May 11, 2021.  You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one procedure code must be submitted for the panel.   We looked at the file and Medicare rules. In this case, multiple unbundled codes were billed for a single panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81162, 81292, 81321) provided May 11, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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.   Our physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute or complex rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) rendered on August 2, 2021. We have also decided that the Plan does not have to waive the coinsurance for carpal tunnel surgery (64721) rendered on August 19, 2021.  You asked the Plan to waive the copayment for a specialist office visit. You say that you were told the provider took your insurance and were told at the checkout window that you did not owe anything. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for out-of-network provider and professional services in a specialist's office. Your contract with the Plan also clearly says that enrollees must pay a 50% coinsurance for out-of-network surgery services in an outpatient hospital.   You have been asked to pay a $65 copayment for a specialist office visit. You have also been asked to pay  This means that you have been asked to pay $238.36 in coinsurance, which is 50% of the allowed amount for carpal tunnel surgery ($476.73 allowed amount x 50% coinsurance = $238.36). Even though a provider accepts your insurance, the provider may not be in-network with your Plan, and there may still be cost sharing amounts you are responsible for. This means that you have been charged 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 office visit (99203) rendered on August 2, 2021. We have also decided that the Plan does not have to waive the coinsurance for a carpal tunnel surgery (64721) rendered on August 19, 2021.  Your complaint about potentially having already paid $150 on August 19, 2021, 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 short latency somatosensory evoked potential study (95938) central motor evoked potential study (95939) needle electromyography (95870) continuous intraoperative neurophysiology monitoring (G0453) provided June 16, 2021.  You asked the Plan to pay for the neuromonitoring service. You say that requesting reconsideration for procedures as medically necessary. The Plan denied your request. The Plan says the claim was not billed with the appropriate primary diagnosis.  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 find that CPT codes 93938, 95939, 95870 and G0453 is not supported in the medical record. Specifically, the diagnosis is not covered. The diagnosis billed on the claim does not match the primary diagnosis listed in the LCD's. A corrected claim with appropriate primary diagnosis must be resubmitted. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring service have not been met. Therefore, we decided that the Plan does not have to pay for short latency somatosensory evoked potential study (95938) central motor evoked potential study (95939) needle electromyography (95870) continuous intraoperative neurophysiology monitoring (G0453) provided June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a spinal cord stimulator trial.  You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific conditions are met.  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 a spinal cord stimulator trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain, but the workup is not complete. There is no evaluation by a surgeon to see if surgery can fix the problem.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal cord stimulator trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core build up (D2950) provided on September 1, 2021.  You asked the Plan to pay for the dental service. You say that you told the office 3 separate times to not exceed billing you over $3,000 for dental procedure. You say that you received a back charge for $3,860. You also say that you are a low income senior and are limited in your expenses. The Plan denied your request. The Plan says core build up 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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the blood smear and flow cytometry services provided on August 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the blood smear and flow cytometry services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 blood smear and flow cytometry services provided on August 25, 2021 by an out-of-network (OON) provider.