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

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 10, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows that the enrollee was in a skilled nursing facility (SNF) for this date of service. The SNF must bill radiology services furnished its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS). Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an osteogenesis stimulator is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a nondisplaced fracture of the fourth metatarsal bone in the right foot. An x-ray from May 25, 2021 demonstrated subtle callus
formation. X-rays taken 90 days apart are not provided and 90 days have not passed since the day of the surgery. The criteria for coverage are not met; therefore, the services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the ureterolysis services coded 50715 provided on September 1, 2020.
You asked the Plan to pay for the ureterolysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the code billed is included in another 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, the CPT Code Manual definition of code 50715 is ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis.
We find that CPT code 50715 is not supported in the medical record. Specifically, this code is included in code 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral). The documentation does not support that the procedure or service was distinct or independent from other service performed. Based on this information, we decided that Medicare rules for coverage of the ureterolysis services have not been met. Therefore, we decided that the Plan does not have to pay for the ureterolysis services coded 50715 provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory (E0673) provided October 27, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this device is not covered by Medicare.
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 is used in the treatment of peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. If the base PCD is not covered, related accessories are 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. This item is statutorily excluded from Medicare coverage. In this case, since the base PCD is not eligible for coverage the related accessories are not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory (E0673) provided October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it was not expected you would improve in a reasonable period of time beyond the dates in question as you are not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospitalization have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means inpatient psychiatric hospitalization is not reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the amputation of lower leg provided to the enrollee on
October 18, 2020.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan
denied your request. The Plan says that Medicare rule for payment of this date of service October 18, 2020
claim has not been met.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 27880 is 1. The MAI value for this code is 2. You billed 4 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the amputation of
lower leg provided to the enrollee on October 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on February 14, 2021.
You asked the Plan to pay for endodontic therapy. You say that you had a bad pain in your tooth and your doctor did the root canal. You say that this was an emergency problem and should be paid. The Plan denied your request. The Plan says out-of-network services are not covered.
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 endodontic therapy provided on February 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia supplies provided on January 28, 2021.
You asked the Plan to pay for Iv tubing extension set (S1015) and infection control supplies, not otherwise specified (S8301). You say that the services were requested by in-network providers. The Plan denied your request. The Plan says the claim was billed with CPT codes invalid for usage with Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. These codes may not be used to bill services paid under any Medicare payment system. Medicare does not reimburse for services under S codes. Based on this information, we decided that Medicare rules for coverage of Iv tubing extension set (S1015) and infection control supplies, not otherwise specified (S8301) have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia supplies provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99204 provided on April 1, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation shows that the enrollee previously had an office visit on January 12, 2021 that was provided by a provider with the same tax identification number. This means that the coding criteria for a new patient visit has not been met. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on April 6, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes A9279 and S8301 are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes A9279 (monitoring feature/device) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 17, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
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 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 laboratory services rendered on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening testing provided on February 18, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says this testing is not a Medicare covered screening service.
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. We looked at the file and the rules. The records provided do not indicate the testing was ordered by the enrollee's treating physician for a specific medical problem. The testing services were 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 cardiovascular screening testing provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray provided on March 9, 2021.
You asked the Plan to pay for the intraoral complete series x-ray. You say that you went for a second opinion and a full mouth series of x-rays were taken again. You say that the denied x-rays should be paid as they were necessary to give a proper diagnosis. The Plan denied your request. The Plan says a full mouth series of x-rays is only covered once every five years.
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, you also have a maximum benefit of one full mouth x-ray every five years. The Plan paid for a panoramic x-ray provided on June 24, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray provided on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left lower extremity tributary vein sclerotherapy and
stab phlebectomy.
You asked the Plan to pre-approve left lower extremity tributary vein sclerotherapy and stab phlebectomy. You
say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria
have not been met.
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries
are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be
considered medically necessary if saphenous reflux is not present or already successfully eliminated
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 left lower extremity tributary vein
sclerotherapy and stab phlebectomy. Our reviewer says that the requested services are not medically necessary.
Our physician reviewer found in this case the record indicates that the enrollee has varicose veins and has been
approved for treatment of left greater saphenous vein. The saphenous reflux has not yet been treated. The
elements of the coverage rule are not satisfied. The requested service is not 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 left lower extremity tributary vein sclerotherapy and stab phlebectomy have not
been met. Therefore, we decided that the Plan does not have to pre-approve left lower extremity tributary vein
sclerotherapy and stab phlebectomy
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says there are not enough scientific studies to
show that inserting a device to open the narrowed space would be safe and effective.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 12, 2021.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional component/technical component of 3. This means this code is for a technical component only and should be reported in the hospital setting. The documentation shows that this claim was billed in an outpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 12, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopic gastric bypass and Roux-en-Y gastroenterestomy.
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says that this does not meet medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve the procedures. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a recurrent hiatal hernia with gastroesophageal reflux with class D esophagitis. The enrollee has an esophageal stricture. The enrollee previously underwent nissen fundoplication. The requested procedure is not being performed for weight loss. The records provided are sufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested procedure for the enrollee's condition. The elements of the coverage criteria are satisfied. 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 procedures have been met. Therefore, we decided that the Plan has to pre-approve a laparoscopic gastric bypass and Roux-en-Y gastroenterestomy.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures provided on February 13, 2020.
You asked the Plan to pay for the dentures. You say that the dental clinic assured you the insurance would cover the treatment plan. The Plan denied your request. The Plan says services performed by an out-of-network provider area not covered.
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 file shows that dentures were received by an out-of-network provider. We looked at the file, and Medicare rules. Your plan only covers dentures when received by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pay for the dentures provided on February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for implantation of hormone pellets (estradiol/testosterone) provided on January 20, 2021.
You asked the Plan to pay for hormone pellets. You say that your estradiol counts are erratic and this medicine has improved your health greatly. The Plan denied your request. The Plan says the denial of payment for this drug is correct, because there is no Food & Drug Administration approved formulation of implantable hormone pellets available and these have been shown to produce unpredictable and fluctuating concentrations of estrogen.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 hormone pellets. Our reviewer says that this service does not meet the Medicare criteria for coverage. Our physician reviewer found the indication for this treatment is not clearly stated, but appears to be for subjective symptoms of menopause and/or fluctuating hormone levels. Hormone levels are expected to decrease with age. Supplementing hormone levels during peri-menopause is reasonable therapy, but is not to be provided indefinitely. The lab results provided show elevated hormone levels while on hormone therapy and, therefore, can provide no diagnostic evidence of physiologic hormone deficiency. The documentation does not support that the requested medication was medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hormone pellets have not been met. Therefore, we decided that the Plan does not have to pay for implantation of hormone pellets (estradiol/testosterone) provided on January 20, 2021.