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

We decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on May 13, 2020, billed with code 71045-26.
You asked the Plan to pay for the chest x-ray interpretation. You say that multiple exams were provided on this date of service. The Plan denied your request. The Plan says the radiology group billed and was paid for code 32555. Code 71045 cannot be paid on the same date without a modifier.
The Plan must follow Medicare rules. Medicare rules say that Column 2 codes can only be paid when billed with a Column 1 code when a modifier is used to bypass the NCCI edit.
In this case, the billing provider was paid for code 32555. Code 71045 is a Column 2 code in relation to 32555. No NCCI modifier was used to allow both to be paid to the same billing provider. Therefore, we decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on May 13, 2020, billed with code 71045-26.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transection/avulsion of extradural spinal nerves (64772) and unlisted spinal procedure (22899) provided on March 9, 2021.
You asked the Plan to pay for the services as billed. You say that this is billed correctly. The Plan denied your request. The Plan says 64772 is included in payment for 63101. Code 22899 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 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 that 64772 is payable when billed with 63101, nor is the use of unlisted code 22899 supported. Our reviewer found the code 63101 is defined as a vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve
root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment. 64772 describes a component service which is necessary to complete the lateral extracavitiary approach of the 63101 procedure. It is an accepted standard of care when performing the comprehensive service, and is not a separately distinguishable procedure when performed with the comprehensive service. The operative report did not include documentation of an unlisted procedure of the spine, and therefore, code 22899 cannot be verified. The requested procedure code is not substantiated by the clinical documentation in the operative report available in the case file. We looked at this 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 transection/avulsion of extradural spinal nerves (64772) and unlisted spinal procedure (22899) provided on March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with computed tomography (CT) for attenuation.
You asked the Plan to pre-approve a PET scan with CT for attenuation. 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 a fluorodeoxyglucose (FDG) PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. 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 PET scan with CT for attenuation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not indicate that the enrollee satisfies the requirements for the diagnosis of both Alzheimer's dementia and frontotemporal dementia.
The record does not indicate that the enrollee is in an approved Practical Clinical Trial Utilizing a Specific Protocol to Demonstrate the Utility of FDG PET in the Diagnosis, and Treatment of Neurodegenerative Dementing Diseases. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan with CT for attenuation have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with computed tomography (CT) for attenuation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services coded as D4341, D9230, D0210 provided April 29, 2021.
You asked the Plan to pay for the dental services. You say that you were told that you needed to see a periodontics dentist's. You were never once told anything about Medicare opt-out. You are retired and on a fixed income. The Plan denied your request. The Plan says services were received from an opt out provider. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive
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 the dental services coded as D4341, D9230, D0210 provided April 29, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the mobile imaging services provided on April 23, 2021.
You asked the Plan to pay for the services provided. You say that a complete evaluation was necessary. The Plan denied your request. The Plan says that the code should be reported in a hospital setting.
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. The records show that the services at issue were provided at a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan has to pay for the mobile imaging services provided on April 23, 2021.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377).
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options with their own switches.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is medically necessary for a function detailed in the Local Coverage Article. 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 an expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the patient's strength and function in the upper extremities supports that this patient can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient counseling services rendered on June 10, 2021.

You asked the Plan to pay for these services. You say that you researched a provider that could provide the care you need. The Plan denied your request. The Plan says the provider type is not covered.

The Plan must follow Medicare rules. The rules say that a Licensed Professional Counselor (LPC) is not eligible to participate in Medicare. 

We looked at the file and Medicare rules. The file shows that the provider is a Licensed Professional Counselor. This provider type is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the outpatient counseling services rendered on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Toric astigmatism correcting lens (V2787).

You asked the Plan to pre-approve a Toric astigmatism correcting lens. You say that you need this lens following surgery. The Plan denied your request. The Plan says only a conventional lens is covered.

The Plan must follow Medicare rules. The rules say that Medicare covers the insertion of conventional intraocular lenses (IOLs). Medicare doesn't cover surgical correction, eyeglasses, or contact lenses to correct presbyopia or astigmatism. 

The lens you have requested is used to correct astigmatism and is not covered. Medicare covers only conventional intraocular lenses (IOLs). Therefore, we decided that the Plan does not have to pre-approve a Toric astigmatism correcting lens (V2787).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the spinal injection procedure you had at an
ambulatory surgery center on July 10, 2020.

You asked the Plan to waive the deductible for the spinal injection procedure. You say that you disenrolled
from the Plan prior to these services, so these claims should be paid by Original Medicare. The Plan denied
your request. The Plan says you were charged this deductible correctly. The Plan says that you were not
disenrolled from the Plan until July 31, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1000 deductible which applies to outpatient surgery.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible
which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the
time the spinal injection procedure was received on July 10, 2020. Therefore, we decided that the Plan does not
have to waive the deductible for the spinal injection procedure you had at an ambulatory surgery center on July
10, 2020.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a question regarding your enrollment
in the Plan. The QIC cannot answer enrollment questions. The QIC is sending a copy of your case file and your letter to the Philadelphia CMS Regional Office so that it can look into
your enrollment question.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit coded as 99212-25
provided on December 15, 2020.
You asked the Plan to pay for the office or other outpatient visit. You say that you would like this claim
reprocessed based on the documentation that supports the -25 modifier. The Plan denied your request. The Plan
says the use of the -25 modifier 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.
In this case, the CPT Code Manual definition of code 99212 is office or other outpatient visit for the evaluation
and management of an established patient, which requires at least 2 of these 3 key components: A problem
focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or
coordination of care with other physicians, other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting
problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or
family.
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 office or other outpatient visit. Our reviewer says that the
documentation does not support the -25 modifier. Our reviewer found the enrollee is a 66-year-old woman with
osteoarthritis and pain in her right knee. On February 17, 2021 the enrollee was seen in the orthopedic office
for viscosupplementation injection in her knee. The documentation does not support that the enrollee in this
case received an Evaluation and Management (E/M) service on the same day when another service was
provided to the patient by the same provider.
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 office or other outpatient visit have not been met. Therefore, we decided that
the Plan does not have to pay for the office or other outpatient visit coded as 99212-25 provided on December
15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services coded as G0156 provided October 2, 2021, to October 17, 2021.
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the documentation submitted did not include documentation of note and time so the billed service cannot be verified.
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 G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes We find that CPT code G0156 is not supported in the medical record. Specifically, there is no documentation
presented of time stamps indicating the length of time this service was performed. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services coded as G0156 provided October 2, 2021, to October 17, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on May 22, 2021, to May 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for hearing aids. You say that you did not know this provider was not a network provider and you do not understand why the hearing aids cannot be approved when you tried to save the Plan money. The Plan denied your request. The Plan says services were provided 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 requested provider in this case is not a network provider with the Plan. The EOC confirms that to be covered, you must use a plan approved provider. 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 hearing aids provided on May 22, 2021, to May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, with removal of tumor(s), polyp(s), lesion(s) by snare technique (45385) provided April 13, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the $300 copay is too much money. You feel this was a preventive colonoscopy rather than diagnostic. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $325 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.

You have been asked to pay $325 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 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 copayment for the colonoscopy, with removal of tumor(s), polyp(s), lesion(s) by snare technique (45385) provided April 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy and occupational therapy to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical therapy and occupational therapy to be provided by an OON
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are innetwork
providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 items/services at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided
that the Plan does not have to pre-approve physical therapy and occupational therapy to be provided by an outof-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 Single Power Option power wheelchair (K0836) and accessories (E1002, E1012, E2311, E2361, E1028).

You asked the Plan to pre-approve a Group 2 Single Power Option power wheelchair and accessories. You say that these items are medically necessary. The Plan denied your request. The Plan says the submitted records do not support this request.

The Plan follows Medicare rules. Medicare rules say that a Group 2 Single Power Option power wheelchair is covered if the beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick, or the beneficiary meets coverage criteria for a power tilt or a power recline seating system. A power seating system - tilt only, recline only, or combination tilt and recline will be covered if the beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or the beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or the power seating system is needed to manage increased tone or spasticity. 

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 Group 2 Single Power Option power wheelchair and accessories. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the records do not show that the beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick. There is also no documentation that the patient has one of the following: High risk of a pressure ulcer/unable to perform a functional weight shift, utilization of intermittent catheterization for bladder management/unable to transfer independently from wheelchair to bed or the need of a power seating system to manage increased tone or spasticity. 

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 Group 2 Single Power Option power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 Single Power Option power wheelchair (K0836) and accessories (E1002, E1012, E2311, E2361, E1028).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy (45385, 45381, 45380) and an esophagogastroduodenoscopy (43239) provided on May 6, 2021.
You asked the Plan to pay for a colonoscopy and an esophagogastroduodenoscopy. You say that the claim is coded correctly per CMS coding guidelines. The Plan denied your request. The Plan says the records did not support the services provided on May 6, 2021.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. An operative report was not provided for the service at issue; therefore, the billed services are not supported. Based on this information, we decided that Medicare rules for coverage of a colonoscopy and an esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a colonoscopy (45385, 45381, 45380) and an esophagogastroduodenoscopy (43239) provided on May 6, 2021.