Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth #22, #23, #24, #25, #26 and #27.  You asked the Plan to pre-approve the crowns. You say that these services are necessary, and you do not understand the reason for the denial. The Plan denied your request. The Plan says that crowns may only be covered when the tooth shows signs of decay. Crowns are not covered to fix a tooth that has worn away. The documentation provided indicates that these crowns are not requested due to tooth decay, and therefore these services are not medically necessary.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns when the services are medically necessary and reasonable.  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 crowns. Our reviewer says that the placement of crowns on teeth #22-#27 is medically reasonable and necessary to provide adequate function and protect the teeth from further breakdown. Our physician reviewer found a review of the enrollee's dental records and x-rays indicate that these teeth have worn and fractured incisal edges. The enrollee reports symptoms of sensitivity, difficulty in eating and sharp edges cutting the intraoral tissue. Our reviewer says that the requested services are not cosmetic; the only way to restore these teeth to normal function and prevent further fracturing is the placement of crowns.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have been met. Therefore, we decided that the Plan has to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth #22, #23, #24, #25, #26 and #27.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 21, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 out of network physician services provided to the enrollee on June 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that you are status post stent placement and were found to have non acute compression fractures. The Plan denied your request. The Plan says this is not reasonable and necessary.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not qualify for SNF coverage, as there are no documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care, such as home with services, assisted living, or long term 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records do not show you require skilled nursing or skilled rehabilitation services at this time.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the third level of facet joint injection provided on April 27, 2021, billed with code 64495.  You asked the Plan to pay for the third level of facet joint injection. You say that it is felt that the records support medical necessity for all three levels. The Plan denied your request. The Plan says the third level was correctly denied as not medically necessary.  The Plan follows Medicare rules. Medicare rules say that up to two levels of facet joint injections are covered with additional levels only covered when specifically shown to be uniquely medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the third level of facet joint injection. Our reviewer says that the documentation does not support the medical necessity of a third level for injection. Our physician reviewer found the enrollee has chronic axial low back pain. The LCD limits facet blocks to 2 levels unless there is a very clear indication that more than 2 are needed. That is not the case here. Only 2 levels were medically reasonable and 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 third level of facet joint injection have not been met. Therefore, we decided that the Plan does not have to pay for the third level of facet joint injection provided on April 27, 2021, billed with code 64495.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (93971) provided on March 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says modifier -59 is not supported in this case.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the use of modifier -59 is not supported by the records provided. Our physician reviewer found that procedure codes 36475, 36476, 36478 and 36479, are inclusive of image guidance required for the procedure. Therefore, 93965, 93970 and 93971, will not separately reimbursed when billed in conjunction with 36475, 36476, 36478, and 36479.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (93971) provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (0242U) provided on April 19, 2021.  You asked the Plan to pay for laboratory services. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed with the correct place of service.  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 (0242U) provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 29, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 out of network physician services provided to the enrollee on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5298), hearing service (V5299), and sales tax (S9999), provided on January 28, 2021.  You asked the Plan to pay for the hearing aids, hearing service, and sales tax. You say that the services should be covered. The Plan denied your request. The Plan says you did not receive this service from the Plan's network provider and sales tax is never covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan's network providers.  We looked at  the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids, hearing service, and sales tax have not been met.  Specifically, you did not utilize the Plan's hearing provider to obtain these services. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298), hearing service (V5299), and sales tax (S9999), provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99255) provided October 6, 2020.  You asked the Plan to pay for the physician services. 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 providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99255 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, CPT code 99255 has a status of "I" and is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99255) provided October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (93458) provided on November 30, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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 use of code 93458 is not supported by the records provided. Our reviewer found that per CPT guidelines: Coronary therapeutic services and procedures "diagnostic coronary angiography codes (93454-93461) and injection procedure codes (93563-93564) should not be used with percutaneous coronary revascularization services (92920-92944). Billing CPT 93458 separate from CPT 92928 would result in unbundled codes.  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 the services (93458) provided on November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided April 23, 2021 to
April 30, 2021.
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the enrollee's needs were custodial. 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 pay for the skilled nursing facility services. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no evidence
of an acute decline in function warranting daily skilled services to establish a maintenance program or to
prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical
matter, could be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided
that the Plan does not have to pay for skilled nursing facility services provided April 23, 2021 to April 30,
2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for tuberculosis screening testing provided on May 25, 2021.  You asked the Plan to pay for tuberculosis testing. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare for screening purposes.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, tuberculosis testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for tuberculosis screening testing provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care evaluation service provided on February 27, 2021.  You asked the Plan to pay for critical care evaluation. You say that this code is payable per Medicare billing and coding guidelines. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the critical care time was not documented in the record.  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 99291 is critical care, evaluation, and management of the critically ill or critically injured patient, first 30-74 minutes.  We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not include documentation of the duration of time to support the code billed. Based on this information, we decided that Medicare rules for coverage of critical care evaluation have not been met. Therefore, we decided that the Plan does not have to pay for critical care evaluation service provided on February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on August 27, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 physician services provided to the enrollee on August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium (75571).  You asked the Plan to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service and will be denied as not medically necessary.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the heart with quantitative evaluation of coronary calcium have not been met. Specifically, the request is for a non-covered service. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium (75571).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on June 23, 2021.  You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says this is not a covered screening test.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided June 23, 2021.

You asked the Plan to pay for the chiropractic services. You say that you have attached supporting documentation for date of service 6/23/2021. Please review and reprocess charged for exam 99213 and modalities performed. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary assessment for cardiac conditions provided on April 12, 2021.  You asked the Plan to pay for the hereditary assessment for cardiac conditions. 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.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The hereditary assessment for cardiac conditions test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary assessment for cardiac conditions provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MAKOplasty.  You asked the Plan to pre-approve MAKOplasty. 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 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 MAKOplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested MAKOplasty with right knee surgery in this case, 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 MAKOplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve MAKOplasty.