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

We decided that the Plan does not have to pay for a magnetic resonance angiography (MRA) (70544) provided on June 24, 2021.
You asked the Plan to pay for MRA 70544. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70544 has a procedure-to-procedure (PTP) edit of 1 with code 70553 meaning that this code is not payable without an appropriate modifier which was not billed on this 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 MRA 70544 has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance angiography (MRA) (70544) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 82308, 83735, 85025), the hospital outpatient clinic visit (G0463), and the ultrasound of the head and neck (76536) rendered by the out-of-network (OON) provider on March 29, 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 (80053, 82308, 83735, 85025), the hospital outpatient clinic visit (G0463), and the ultrasound of the head and neck (76536) rendered by the out-of-network (OON) provider on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D1110) provided April 21, 2021.
You asked the Plan to pay for dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is not eligible for payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services (D1110) provided April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral (CPT code 77048).
You asked the Plan to pre-approve the MRI. You say that you want to get this MRI because you have had x-rays done in the pasty and they continue to tell you that nothing is wrong. The Plan denied your request. The Plan says MRI of the breasts is not part of the services that you can get without first getting approval from your doctor.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. You need to obtain a physician order along with medical justification with regards to meeting criteria or having medical necessity. The Plan states your primary care physician (PCP) recommended to start with the diagnostic Mammogram with supplemental ultrasound (US) prior to the MRI. Therefore, we decided that the Plan does not have to pre-approve MRI, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral (CPT code 77048).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found admission to an SNF is not reasonable and not necessary as you have no skilled nursing needs and does not need skilled therapies on a daily basis in an inpatient setting at the current functional level with aggressive IRF level of therapies with minimal progress. Documentation does not support the need for an admission to an SNF. Your rehabilitation needs can be safely met at a lower intensity level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from November 23, 2020, to December 21, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have 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 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 chiropractic services provided from November 23, 2020, to December 21, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity angiography (75716-59) and selective angiography (75774-XS) provided during a surgical procedure on April 21, 2021.
You asked the Plan to pay for the services as billed. You say that this was billed correctly. The Plan denied your request. The Plan says the modifiers are not supported as clinically appropriate.
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only the Column 1 code is payable unless a clinically appropriate modifier is used. 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 as billed.
Our reviewer says that the documentation does not support the use of the billed modifiers to justify separate payment of the codes at issue. Our physician reviewer found in regard to 75716, billing this procedure in addition to CPT 37229 would be inappropriate based on the documentation provided. CPT 75716 would be inclusive to CPT 37229 unless further testing during the procedure is done. Documentation does not support additional testing. Regarding 75774, billing this procedure in addition to CPT 37229 would be inappropriate, as the primary procedure is an interventional procedure, and should not be reported as a diagnostic procedure. 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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the extremity angiography (75716-59) and selective angiography (75774-XS) provided during a surgical procedure on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the incision and drainage of abscess (D7510) provided on June 1, 2020.
You asked the Plan to reimburse you for the dental service. You say that you paid this bill. You also say that you would like to know if any part of this would be covered by your medical insurance. The Plan denied your request. The Plan says incision and drainage of abscess is not listed as a covered dental 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 incision and drainage of abscess is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the incision and drainage of abscess (D7510) provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs to be provided by an out-of-network 
(OON) provider.  
You asked the Plan to pre-approve OON services. You say that you are already familiar with this vendor. The 
Plan denied your request. The Plan says there are preferred providers available.  
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair repairs to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abilify Maintena injections.

You asked the Plan to pre-approve injection, aripiprazole, extended release, 1 mg (J0401). You say that you have tried and failed other medications. The Plan denied your request. The Plan says the requested drug is intended for self-administration.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Abilify Maintena injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit for evaluation and management services coded as 
99347 and 99350 provided August 15, 2019 through December 4, 2019. 
 
You asked the Plan to pay for the home visit services. You say that please find the attached medical records for 
review and process the claim accordingly. The Plan denied your request. The Plan says the records do not 
support the billed service. The submitted codes do not appropriately reflect the services provided. Unable to 
determine services rendered. 
 
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, home visit services (CPT codes 99431-99350) may only be billed when services are provided in 
the beneficiary's private residence (POS-12). To bill these codes, the physician must be physically present in 
the beneficiary's home. The provided records do not support that a physician or non-physician practitioner (PA 
or NP) were physically present. The submitted code does not appropriately reflect the services provided by the 
RN. No medical documents were provided for December 4, 2019 for review. Based on this information, we 
decided that Medicare rules for coverage of the home visit services have not been met. Therefore, we decided 
that the Plan does not have to pay for home visit for evaluation and management services coded as 99347 and 
99350 provided August 15, 2019 through December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scaling and root planing (D4341) provided May 26, 2021 to June 2, 2021.
You asked the Plan to pay for the scaling and root planing. You say that the services were medically necessary. The Plan denied your request. The Plan says these services were not a covered benefit.
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 scaling and root planing (D4341) provided May 26, 2021 to June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint injections.
You asked the Plan to pre-approve lumbar facet joint injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria is 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 lumbar facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found you are not a candidate for facet injections as you have radiculopathy and per the coverage criteria there must be absence of untreated radiculopathy or neurogenic claudication. The review has determined that you do not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided November 23, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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 CPT code G0483 is not supported in the medical record. Specifically, the place of services billed on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 17, 2020.
You asked the Plan to pay for an eye refraction. You say that the provider will not bill two different places and would like the Plan to send a check for the refraction that you paid. The Plan denied your request. The Plan says an eye refraction is not covered if performed by a specialist listed in the provider directory.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is obtained through one of the Plan's routine vision service vendors. We looked at the file and the Plan's rules. The records show that the eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. An eye refraction is not covered if performed by a provider that is not part of the Plan's routine vision service vendors. The provider at issue is not one of the Plan's routine vision service vendors. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography, head or brain (70450) provided December 27, 2020.
You asked the Plan to pay for the diagnostic services. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the 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 find that CPT code 70450 is not supported in the medical record. Specifically, on the same date of service the enrollee also had a computed tomography, head or brain; without contrast material (70496). Procedure 70496 is a more comprehensive procedure that includes imaging procedure 70450. The plan made multiple attempts to obtain additional information from the provider. The provider has not submitted any clinical records to support the medical necessity of the services. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography, head or brain (70450) provided December 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal to be performed by a periodontist.

You asked the Plan to pre-approve a root canal to be performed by a periodontist. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 says covered dental services must be performed by a participating general dentist. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a root canal to be performed by a periodontist have not been met. Therefore, we decided that the Plan does not have to pre-approve a root canal to be performed by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided June 9, 2021.
You asked the Plan to pay for the tooth extraction. You say that the service should be covered. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan 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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found admission to an SNF is not reasonable and not
necessary as you have no skilled nursing needs and does not need skilled therapies on a daily basis in an
inpatient setting at the current functional level. Documentation does not support the need for an admission to an
SNF. Your rehabilitation needs can be met at a lower intensity level.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.