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

 We decided that the Plan does not have to pay for the collection of venous blood by venipuncture (36415, 85610) provided on June 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the collection of venous blood by venipuncture. You say that you would like for the Plan to reconsider the denial for coverage for this member so that they can continue care with their established provider. You also say that the provider has requested in-network participation. The Plan denied your request. The Plan says Medicare rules say that the Plans can require enrollees to get care from network providers. The Plan also says this provider is not a network provider with them. The Plan says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The 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 the collection of venous blood by venipuncture (36415, 85610) provided on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye exam and external ocular photography with interpretation and report for documentation of medical progress (92012, 92285) provided on August 27, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an eye exam and external ocular photography with interpretation and report for documentation of medical progress. You say that the patient presented to this provider in regard to an eye issue. The Plan denied your request. The Plan says this provider is not a network provider with this Plan. The plan says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The 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 an eye exam and external ocular photography with interpretation and report for documentation of medical progress (92012, 92285) provided on August 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for specialist office visits and for the destruction of premalignant lesions (99203, 99214, 17000, 17003, 17004, 17110, 11300) provided on March 2, 2021 to April 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for specialist office visits and for the destruction of premalignant lesions. You say that while you were out of state, you and your family thought you had cancer and that you were told by the insta-care office and the emergency room to see a dermatologist. You also say that you went to the dermatologist because you would not return home from that state for two months. The Plan denied your request. The Plan says according to the Evidence of Coverage (EOC), out of area coverage extends to Urgent Care and Emergency room visits only. The Plan also says that the enrollee received care from an out of network dermatologist for both dates of 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The 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 specialist office visits and for the destruction of premalignant lesions (99203, 99214, 17000, 17003, 17004, 17110, 11300) provided on March 2, 2021 to April 15, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have difficulty walking due to hammer toes, pronation of both feet, and calluses. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve block radiofrequency ablation (RFA).  You asked the Plan to pre-approve a genicular nerve block 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 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 a genicular nerve block RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic right knee pain due to osteoarthritis, status post right total knee arthroplasty and low back pain with radiation to the right lower extremity. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including degenerative joint disease; osteoarthritis of the knee; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 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 genicular nerve block radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (80307, G0481) rendered by the out-of-network (OON) provider on June 29, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 drug testing services (80307, G0481) rendered by the out-of-network (OON) provider on June 29, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the arm joint (73221).  You asked the Plan to pre-approve MRI services. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI services. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the patient is a 43-year-old female with left shoulder pain which radiates from the neck to her fingers with occasional numbness and tingling in fingers. Reduced range of motion, pain with movement, good strength, normal pulses, and normal neuro exam were noted. Spurling sign mildly positive to left. Diagnosed with impingement vs early adhesive capsulitis. She had tried conservative treatments but was worsening regardless. An MRI of the left shoulder was requested. Due to the patient's symptoms and exam findings worsening in the setting of conservative treatments having been tried, MRI is reasonable and 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 MRI services have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the arm joint (73221).   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided on April 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON lab services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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.  You are 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 lab services provided on April 6, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on August 10, 2021.  You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit with code 70496 so is not separately payable without an appropriate modifier.  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 CT scan 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 a computed tomography (CT) scan (70450) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).  You asked the Plan to pre-approve periodontal scaling and root planing (D4341). The Plan denied your request. The Plan says your x-rays do not show that you have noticeable bone loss or hard substance built up on the root of the tooth.   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 Plan covers periodontal scaling and root planing (D4341) when the services are medically necessary and reasonable.   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 periodontal scaling and root planing (D4341). Our physician reviewer found that the radiographs indicate minor bone loss in the molar region and no more than three teeth exhibiting any significant bone loss. Our reviewer says that given the provided information, the criteria for use of code D4341 has not been met.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing (D4341) have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided to the enrollee on July 2, 2021 and billed under codes 96372 and 96401.  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 a Procedure (PTP) edit exists between codes 96401 and 96372. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed. The records show the enrollee underwent a subcutaneous injection of Xolair on July 2, 2021. Code 96401 remains denied as there is a more appropriate code to describe the services provided.   The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim cannot be paid due to the omission of an appropriate modifier and the guidelines that there is a more appropriate code that should be used instead of code 96401. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on July 2, 2021 and billed under codes 96372 and 96401.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).  You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 85025, 82550, 85610, 85730, 80053, and 84484 provided on January 12, 2021 to January 13, 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 rendered 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.  We find that CPT codes 85025, 82550, 85610, 85730, 80053, and 84484 are not supported in the medical record. Specifically, these codes have a professional component/technical component indicator of 6 and these services are reported under the clinical laboratory code with modifier 26. The billed codes are not listed on the Medicare Physician Fee Schedule Database and therefore, not payable under clinical laboratory interpretation services and the codes were not billed with the required modifier 26. 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 85025, 82550, 85610, 85730, 80053, and 84484 provided on January 12, 2021 to January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).  You asked the Plan to pre-approve a Dexcom CGM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.  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 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 Dexcom CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided on June 10, 2021.  You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of an occupational therapy assistant shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the records do not indicate if the rendering provider was an occupational therapist or an occupational therapy assistant. A nurse practitioner is not able to bill for the services of an OTA because the nurse practitioner is not a therapist. There is no evidence that the nurse practitioner was on the premises to be able to bill for occupational therapy services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate services.  You asked the Plan to pre-approve waterjet ablation services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met at this time.  The Plan follows Medicare rules. Medicare rules say that waterjet ablation of the prostate is subject to the criteria listed 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 waterjet ablation services. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 65-year-old with benign prostatic hyperplasia and prostate cancer. He underwent brachytherapy for stage T1c prostate cancer in 2006 and has no evidence of disease recurrence. In this case, the enrollee does not meet the coverage criteria listed in the LCD for the requested waterjet ablation services. Specifically, symptom score, prostate volume, flow rate, and failure of medical therapy was not provided in the records.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of waterjet ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate services.