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

 We decided that the Plan does not have to pay for lab services provided on September 14, 2020.  You asked the Plan to pay for the lab services. You say that you have provided medical records to substantiate the billing. The Plan denied your request. The Plan says the services cannot be paid as billed. The Plan says that you billed these lab services within place of service 11.  However, the records show that the specimen was collected from the patient in a Healthcare and Rehab center a day prior to the lab receiving the specimen.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, they must complete the 'place of service' fields on the claim form indicating the place where the sample was taken.  In this case, you billed these lab services with Place of Service '11', meaning that the sample was taken in an office setting.    However, the medical records show that the sample was taken from the member the day prior to the lab receiving the sample and the patient was in a rehab center at the time the sample was collected.  The Place of Service billed must be accurate in order for payment to be made. 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 provided on September 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee on
September 23, 2020 billed under code "FFXF".

You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria are not met. The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the billed service does not match the
service approved under the authorization on file. The Plan approved code "FDPF", but the provider has billed
code "FFXF" in error. Insufficient clinical documentation was not available to support the billed code of
"FFXF". The Plan provided the claim image that shows the provider has inappropriately billed code "FFXF".

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, the Plan
provided a copy of the claim showing an inappropriate code was billed based on the services provided.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have
to pay for skilled nursing facility services provided to the enrollee on September 23, 2020 billed under code
"FFXF".
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 3, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an unbundled 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 have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown resin-based composite (D2710) for tooth #12.
You asked the Plan to pre-approve a crown resin-based composite. You say that the tooth is part of the
procedure to place the temporary crown to protect it as the porcelain crown is made. By denying the service,
the Plan is interfering with the procedure already established by your dentist who is authorized to provide the
service. Tooth #12 cannot be exposed while waiting for the crown to arrive. The Plan denied your request. The
Plan says the requested service was not approved because the service is an exclusion from your benefit Plan.
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 pre-approve a
crown resin-based composite (D2710) for tooth #12.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection.

You asked the Plan to pre-approve the epidural steroid injection. You say that the requested epidural injection is medically necessary and beneficial to the enrollee. You say that the code you requested includes fluoroscopy. You say that fluoroscopy is being used when the injection is being done. The Plan denied your request. The Plan says that the clinical information does not describe a plan to use computed tomography (CT) or fluoroscopy guidance with contrast, and therefore the procedure is not indicated.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan's denial reason was not supported or substantiated. The Plan's reason for denial was the provider's plan for treatment not including CT or fluoroscopy guidance with contrast. However, the case file clearly shows that the provider's intention is to use fluoroscopy guidance with contrast. They demonstrated this intention in the code they requested coverage for (62323) and in their appeal letter where they clearly state it. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection.

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 pre-approve topical application of fluoride varnish (D1206).
You asked the Plan to pre-approve fluoride varnish. You say that you feel the services are necessary. The Plan
denied your request. The Plan says fluoride varnish is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested fluoride varnish is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
topical application of fluoride varnish (D1206).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Thera-bite device.
You asked the Plan to pre-approve a Thera-bite device. You say that a Thera-bite device is necessary to help
adjust your jaw and your bite. The Plan denied your request. The Plan says a Thera-bite device is not covered
by the Plan or by Medicare.
Medicare does not cover dental services or dental appliances. 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 more than Medicare coverage, the requested dental appliance is not among those covered under
this benefit. Therefore, we decided that the Plan does not have to pre-approve a Thera-bite device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous implant for the enrollee.

You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these interspinous implants are experimental. More research is needed to show safety and efficacy of the interspinous devices. 

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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous implant for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ultraviolet light system for the enrollee.

You asked the Plan to pre-approve a home ultraviolet light system. You say that a home ultraviolet light system is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for a home ultraviolet light system are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for a home ultraviolet home system. Based on the medical records provided, the enrollee does not meet the criteria needed this equipment to be provided in the home. The enrollee does not have a qualifying diagnosis. If the enrollee did have the required diagnosis, there is no indication that the condition is debilitating to the point where the enrollee cannot leave the home for treatment. Therefore, we decided that the Plan does not have to pre-approve a home ultraviolet light system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing.

You asked the Plan to pre-approve periodontal scaling and root planing. The Plan denied your request. The Plan says the service is 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 pre-approve periodontal scaling and root planing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.

You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not require frequent self- adjustment of insulin dosage based on blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services out of area (OOA).
You asked the Plan to pre-approve the OOA pain management services. You say that you need to see a pain management doctor for pain medication every month because of your chronic back condition. You say that you will be in Florida for 5 months. The Plan denied your request. The Plan says the criteria for coverage of OOA care have not been met.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The rules say that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan. We looked at the file and Medicare rules. The case file shows that the need for the OOA services being requested is not unforeseen. Based on this information, we decided that Medicare rules for coverage of OOA care have not been met. Therefore, we decided that the Plan does not have to pre-approve pain management services out of area (OOA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the crown (D2750) provided on July 6, 2021.
You asked the Plan to pay in full for the crown. You say that you were under the impression that you were eligible for full reimbursement within your allowance. You also say that you were only reimbursed for $300 out of the $900 expense for this service. The Plan denied your request. The Plan says the Health Plan has already issued $1,000 payment for your 2021 non-Medicare covered dental services.
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 Plan pays up to $1,000 every year for non-Medicare covered preventive and comprehensive dental services. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the July 6, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay in full for the crown (D2750) provided on July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready to move to the next level of care, which would be an LTACH. The enrollee has been in the short-term acute care hospital for 51 days. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate care in the current hospital and there is no advantage in transferring to an LTACH at this time. The enrollee can stay in the hospital until they are safe for transfer or discharge.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided December 22, 2020.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for the code billed is bundled in payment for another 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. 

We find that CPT code 99100 is not supported in the medical record. Specifically, the CPT code billed has a status of "B" per the CMS Physician Relative Value File. Payment for this service is always bundled with payment for the primary service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genesight pharmacogenomics testing (81291, 81479) provided on March 25, 2021.

You asked the Plan to pay for Genesight pharmacogenomics testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says the submitted records do not show this was medically necessary.

The Plan must follow Medicare rules. Medicare rules say that in order for any pharmacogenomics testing services to be covered, the patient's medical record must clearly reflect that the criteria for coverage listed in the rules section have been met. 

We looked at the file and Medicare rules. Medical records from the ordering physician have not been submitted to verify that the criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of Genesight pharmacogenomics testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight pharmacogenomics testing (81291, 81479) provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 683 provided from August 17, 2019 to August 20, 2019.

You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683.

The Plan denied your request. The Plan says the medical records do not support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with N17.9. 

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 inpatient hospital services. Our reviewer says that the medical records do not support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683. Our physician reviewer found the review indicates that the documentation supported an admission for dehydration. The documentation was inconsistent or unclear regarding a diagnosis of acute kidney failure. Even though acute kidney failure is documented in the emergency department notes, Nephrology consults notes and discharge summary, supporting documentation was not found within the submitted medical record. The review has determined that the medical records did not support the billing of the principal diagnosis code N17.9: Acute kidney injury (nontraumatic) with DRG 683. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 683 provided from August 17, 2019 to August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR panel testing (CPT code(s): 87799, 87798,
87482, and 87150) provided to the enrollee on August 15, 2021.
You asked the Plan to pay for the testing. You say that the services were denied as experimental in error. The
Plan denied your request. The Plan says the PCR testing is considered unproven and not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found based on currently available high-quality evidence, PCR testing has not shown to lead to better
outcomes than standard testing methods (U/A + culture) in the setting of suspected UTI. Therefore, this request
for such will be considered not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have
to pay for the urine PCR panel testing (CPT code(s): 87799, 87798, 87482, and 87150) provided to the enrollee
on August 15, 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 August 4, 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 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 out of network physician services provided to the enrollee on August 4, 2021.