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

We decided that the Plan does not have to pay for this service.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. 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 this
service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the enrollee was billed
for Current Procedural Terminology (CPT) 14021: Adjacent tissue transfer or rearrangement, scalp, arms
and/or legs and Current Procedural Terminology (CPT) 27635: Excision or curettage of bone cyst or benign
tumor, tibia or fibula. The documentation submitted does not meet the criteria for reimbursement.
For code 14021 the operative report does not describe flat health skin and other tissues were transferred or
transplanted to the area adjacent to the skin defect. Report describes undermining for complex closure. This
procedure should be reported using complex closure code. Therefore, this procedure would not be covered.
For code 27635 the operative report does not document this service was performed in a different anatomical
area as the primary procedure, therefore would be inclusive to the primary procedure performed.
It should be noted that billing CPT 27635 with primary code is considered "unbundling" and should not be
billed separately.
We looked at this review and the Medicare rules. Based on this information, we find the billing criteria for
these services were not met. Therefore, we decided that the Plan does not have to pay for surgery services
provided to the enrollee on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigational orthopedic procedure (0055T) and inpatient hospital services.
You asked the Plan to pre-approve these service. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of computer-assisted musculoskeletal surgical navigational orthopedic procedures has not been demonstrated in the peer-reviewed literature and that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 requested services are not considered medically reasonable and necessary in this case. The literature does not show that computer assisted total knee replacement is better than conventional open surgery. More research is needed. The left total knee surgery may be safely performed as an observational stay of 48 hours and inpatient services are not needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigational orthopedic procedure (0055T) and inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) or pay more for the crown (D2740) provided on April 26, 2021.
You asked the Plan to pay for the core buildup and to pay more for the crown. You say that you were charged a lot more for this dental work than what was shown on the predetermination estimate. The Plan denied your request. The Plan says the core buildup is not a covered service. The Plan also says that your dental maximum has been met.
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, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. The Plan offers a $1,000 annual dental benefit maximum. The record shows that you met the annual maximum benefit while processing this claim for the April 26, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) or pay more for the crown (D2740) provided on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the sleep study (95811) rendered by the out-of-network (OON) provider on May 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 referring primary care physician noted in the record does not appear to be a network provider with the Plan. Since this service was not referred by a network PCP, it cannot be covered under the POS benefit. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the sleep study (95811) rendered by the out-of-network (OON) provider on May 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for this service.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. 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 this
service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the documentation
submitted does not show criteria are met. The anesthesia report does not document pre-operative nerve block
was given. The documentation submitted was difficult to read, but unable to confirm this procedure was
performed.
We looked at this review and the Medicare rules, based on this information, we have determined criteria
needed to pay this claim were not met. Therefore, we decided that the Plan does not have to pay for services
provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nasal endoscopy.
You asked the Plan to pre-approve a nasal endoscopy for the enrollee this service. You say that this service is
medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.
The Plan must follow Medicare rules. Medicare only covers services that are medically necessary. We asked
our physician reviewer to determine if the Plan was correct in denying the request to cover this service. Our
reviewer says that the available documentation does not support that a nasal endoscopy is medically reasonable
and necessary for the enrollee in this case. There is insufficient documentation of chronic sinonasal symptoms.
The enrollee reported no facial pain. The prescribed course of antibiotics has not been completed. We looked at
this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a
nasal endoscopy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extension of home health services.
You asked the Plan to pre-approve the extension. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in an alternate setting, or with an alternate method of treatment through a home exercise program.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 extension. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no documented skilled nursing or skilled therapy needs. You appear to be functioning at a level that allows for transitioning to outpatient care and a home exercise program. As such, the quantity of ongoing home health is not shown to be 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 the extension have not been met. Therefore, we decided that the Plan does not have to pre-approve an extension of home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833), provided on April 5, 2021.
You asked the Plan to pay for a knee brace. You say that the item was medically necessary. The Plan denied your request. The Plan says no delivery confirmation document was received to validate the brace was received by the member.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery. All services that do not have appropriate proof of delivery will be denied. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833), provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on March 29, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and you are the sole laboratory which performs this test. The Plan denied your request. The Plan says this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with procedure code 81479 for date of service March 29, 2021. We looked at the file and Medicare rules. This testing was not billed with the appropriate procedure code. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services provided from April 1, 2021, to May 4, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee did not exceed the allowable visits. The Plan denied your request. The Plan says that the provider type is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file, and Medicare rules. The NPI on the billed claims shows the provider is a Doctor of Oriental Medicine. Based on this information, we decided that Medicare rules for coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for the acupuncture services provided from April 1, 2021, to May 4, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on May 27, 2021.
You asked the Plan to pay for the bone replacement graft (D7953). You say that you paid $1,125 and want the decision reconsidered. 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 pay for the bone replacement graft (D7953) provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on April 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services rendered by non-participating providers require 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the rest home visit provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan interpretation provided on May 2, 2021.
You asked the Plan to pay for duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971-26). You say that the enrollee had multiple exams on this date of
service. The Plan denied your request. The Plan says an appropriate National Correct Coding Initiative modifier was not billed with this Procedure to Procedure edit.
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 duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971-26) has a bundled relationship with code 93970 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 duplex scan interpretation provided on May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), and an electronic connection between wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve an expandable controller, harness for upgrade to expandable controller, and an electronic connection between wheelchair controller and two or more power seating system motors. You say that the items 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 wheelchair accessories are 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 an expandable controller, harness for upgrade to expandable controller, and an electronic connection between wheelchair controller and two or more power seating system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer found your strength and function in the upper extremities with the ability to feed yourself indicates that you 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, harness for upgrade to expandable controller, and an electronic connection between wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), and an electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) rendered by the out-of-network (OON) provider on June 8, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) rendered by the out-of-network (OON) provider on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a fixed partial denture sectioning (D9120) provided on July 22, 2021.
You asked the Plan to pay for a fixed partial denture sectioning. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue 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 pay for a fixed partial denture sectioning (D9120) provided on July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services billed with code 75887 provided to the enrollee on
January 13, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. 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 this
service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the documentation
submitted does not support reimbursement. The procedure report does not document visualization of the portal
veins. The operative report describes hepatic arteriography. Code 75889 is an incorrect code to report for this
procedure, and therefore code would not be covered in this case.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pay for Percutaneous transhepatic portography without hemodynamic evaluation, radiological
supervision and interpretation (code 75887) provided to the enrollee on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you need to check your blood sugar. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
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 the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sure Grip's FeatherLite hand controls.
You asked the Plan to pre-approve Sure Grip's FeatherLite hand controls. You say that this equipment is necessary for you to drive safely. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve Sure Grip's FeatherLite hand controls.