Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medial branch blocks (MBBs) provided on July 29, 2021.
You asked the Plan to pay for the injections. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that MBBs are covered for the indications established in
the applicable LCD.
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 injections. Our reviewer says that the requested MBBs are not medically reasonable and necessary. Our physician reviewer found that the LCD treatment algorithm is for radiofrequency ablation (RFA), not a continuing series of diagnostic blocks. The procedure was 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 the injections have not been met. Therefore, we decided that the Plan does not have to pay for the medial branch blocks (MBBs) provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram coded 93042 provided on January 13, 2021.

You asked the Plan to pay for the rhythm electrocardiogram. 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, we have confirmed that code the rhythm electrocardiogram is a column II code to column I code 93042 for 32551.

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 the rhythm electrocardiogram coded 93042 provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care evaluation and management service (99291)
provided on February 28, 2021.
You asked the Plan to pay for critical care 99291. You say that according to Medicare guidelines, this code is not included in an anesthesia service and will be separately reimbursed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99291 has a medically unlikely edit (MUE) value of 1, but 1 unit of this code was already paid.
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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of critical care 99291 have not been met. Therefore, we decided that the Plan does not have to pay for critical care evaluation and management service (99291) provided on February 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left sacroiliac (SI) joint radiofrequency ablation (RFA) identified with code 64636.
You asked the Plan to pre-approve a left sacroiliac (SI) joint radiofrequency ablation (RFA). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain indications. 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 left sacroiliac (SI) joint radiofrequency ablation (RFA). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee was diagnosed with sacroiliac joint pain. Based on the submitted documentation, the pain is worse now compared to last year. The documentation indicates that the enrollee is doing physical therapy and a home exercise program with little results. According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain. Therefore, the enrollee does not meet criteria for the requested 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 a left sacroiliac (SI) joint radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve a left sacroiliac (SI) joint radiofrequency ablation (RFA) identified with code 64636.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided May 4, 2020 to May 29, 2020.

You asked the Plan to pay for the dialysis services. You say that you are requesting reconsideration of the denial of your claim as you did everything in your power to file your claim timely. The Plan denied your request. The Plan says the provider must correct the claim with the required information.

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 90999 is unlisted dialysis procedure, inpatient or outpatient.

We find that CPT code 90999 is not supported in the medical record. Specifically, in order for the dialysis charges to process for payment, value code D5 needs to be billed on the claim. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services provided May 4, 2020 to May 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the blepharoplasty services coded 15823 provided on May
19, 2021.
You asked the Plan to pay for the blepharoplasty services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a
distinct procedural service. Providers must report services with the appropriate CPT code. In this case, we have
confirmed that code the blepharoplasty services is a column II code to column I code 15823 for 67904. 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.
In addition, the medical records provided do not show that the service billed with the -59 modifier is a distinct
procedural service. Specifically, the documentation does not support that the procedure was distinct or
independent from the other services performed. Based on this information, we decided that Medicare rules for
coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not
have to pay for the blepharoplasty services coded 15823 provided on May 19, 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 April 19, 2021 under code 99053.
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 that procedure 99053 has a status indicator of 'B' and is always bundled into payment for other services not specified. No separate payment is made for this code on Medicare claims.
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 99053 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 19, 2021 under code 99053
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered on June 3, 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 the services are not covered.

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 95812 is electroencephalogram (EEG) extended monitoring; 41-60 minutes. 

We find that CPT code 95812 is not supported in the medical record. Specifically, the records show that an EEG during nonintracranial surgery was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 95822 (electroencephalogram [EEG]; recording in coma or sleep only), G0453 (continuous intraoperative neurophysiology monitoring, from outside the operating room [remote or nearby], per patient, [attention directed exclusively to one patient] each 15 minutes [list in addition to primary procedure]), and 95812. Codes 95822 and G0453 are column II codes with a modifier indicator of 1 when billed with column I code 95812. The column II codes were not billed with an appropriate modifier to allow for separate payment.

Therefore, we decided that the Plan does not have to pay for the testing rendered on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750), provided on March 24, 2021.
You asked the Plan to pay for the crown. You say that the service should be covered. The Plan denied your request. The Plan says this is not 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 items or services are not among those covered under this benefit. Specifically, this service is not listed in the Plan's benefit chart. This means it is not covered. Therefore, we decided that the Plan does not have to pay for the crown (D2750), provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not
need an intensive team treatment or frequent physician interventions during rehabilitation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our physician reviewer found
that the enrollee was admitted to the acute care hospital for syncope and surgical repair of a hip fracture after a
fall. His medical problems are stable. He does not require treatment by multiple therapies in an intensive
rehabilitation therapy program. While he has a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on July 15, 2021.

You asked the Plan to pay for the resin-based composites. You say that you had radiation therapy to your neck which caused your teeth to decay. You say that you want to appeal the decision. The Plan denied your request. The Plan says the $1,000 benefit maximum was met before the processing of this 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, you also have an annual maximum of $1,000 toward covered dental services every year. The Plan paid $1,000 toward the dental services received in 2021 prior to receiving these services, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on June 11, 2021.
You asked the Plan to pay for the hearing aids. You say that you went through the network provider and it was twice the cost of what you paid at this provider. You say that you should be reimbursed. The Plan denied your request. The Plan says this provider is an out-of-network provider.
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 2 hearing aids per year when they are received from the Plan's hearing aid vendor. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your needs can be met in a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the available records, you are medically stable. You do not require a physician's supervision three times a week in an IRF. You have no acute rehab nursing needs. Based upon your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach to daily therapy. You will not retain the learned functional skills from physical and occupational therapy due to Dementia as evidenced by your hospital discharge functional status at the time of referral to IRF admission as noted above. IRF admission is not medically necessary. While you may benefit from physical and occupational therapies, your rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility with intermittent therapies or continuation of therapies at home. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 81301 provided on May 6, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 81206, 81292, and 81301 are not supported in the medical record. Specifically, if laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file does not support that only one code was submitted for the panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81292, and 81301 provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unlisted special service to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal.
We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an unlisted special service to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous sacroiliac (SI) joint fusion.
You asked the Plan to pre-approve the SI joint fusion. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of a minimally invasivepercutaneous sacroiliac (SI) fusion in the setting of multifactorial low back pain radiculopathy, and bilateral SI joint pain have not been demonstrated in the peer-reviewed literature.
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 SI joint fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Percutaneous SI joint fusion is experimental. SI joint fusion with back pain and lumbar degeneration remains controversial as a treatment option and more research is needed to show its safety and efficacy. We decided that the Plan does not have to pre-approve Percutaneous sacroiliac (SI) joint fusion.
You asked the Plan to pre-approve the SI joint fusion. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of a minimally invasivepercutaneous sacroiliac (SI) fusion in the setting of multifactorial low back pain radiculopathy, and bilateral SI joint pain have not been demonstrated in the peer-reviewed literature.
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 SI joint fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Percutaneous SI joint fusion is experimental. SI joint fusion with back pain and lumbar degeneration remains controversial as a treatment option and more research is needed to show its safety and efficacy.