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

 We decided that the Plan does not have to pay for morphometric analysis provided to the enrollee on March 29, 2021.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the diagnosis code billed does not support medical necessity.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this diagnosis code (K22.70) does not support medical necessity as there is not sufficient high quality evidence yet to support its regular use over standard biopsy.      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 services have not been met. Therefore, we decided that the Plan does not have to pay for morphometric analysis provided to the enrollee on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of a spinal fixation device provided on June 24, 2021.  You asked the Plan to pay for the services provided. You say that the records show the service was separate. The Plan denied your request. The Plan says the service cannot be separately reimbursed. The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  In this case, the CPT Code Manual definition of code 22845 is anterior instrumentation; 2 to 3 vertebral segments. We looked at the file and the rules. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. 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 insertion of a spinal fixation device provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on June 3, 2021.  You asked the Plan to pay for office visit. You say that this claim was coded and billed correctly. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the record shows that an emergency department evaluation was performed so code 99214 is not appropriate.  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 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.  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 office visit. Our reviewer says that code 99214 does not meet the criteria for payment. Our reviewer found the documentation supports that a cardiology consult was performed, however documentation does not confirm this service was provided in emergency room - hospital, as place of service 23 emergency room - hospital was billed. Therefore, the place of service cannot be confirmed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided on May 19, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized.  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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical criteria for coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Pegfilgstrim (Ziextenzo) is Food and Drug Administration (FDA) approved to decrease the incidence of infection (as manifested by febrile neutropenia), in patients with non-myeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. The enrollee's regimen - FOLFIRI panitumuamb - is not associated with as significant risk of neutropenic fever. There is no evidence of neutropenia with the provided laboratory results. The service is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953 x3), guided tissue regeneration resorbable barriers (D4266 x3) and surgical access to an implant surgery (D6011)  You asked the Plan to pre-approve bone replacement grafts, guided tissue regeneration and surgical access to an implant surgery. You say that you need these dental services because your teeth are infected, which has caused you to also experience other health conditions. You also say that you do not have the financial resources to pay for this on your own. You are asking the Plan to review and reconsider coverage. The Plan denied your request. The Plan says the services at issue are not covered benefits.  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 bone replacement grafts for ridge preservation (D7953 x3), guided tissue regeneration resorbable barriers (D4266 x3) and surgical access to an implant surgery (D6011)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for biofeedback training by any modality (CPT code 90901) provided on May 5, 2021.

You asked the Plan to pay for the services. You say that you had Lens therapy to help stimulate your brain since your stroke. You state that is getting more feeling to your right side, your balance is more controlled, and it is beneficial to your recovery. The Plan denied your request. The Plan says based upon their criteria and assessment of the peer-reviewed literature, there is no consistent evidence that biofeedback, alone or as an adjunct to other treatments, demonstrates improvement in patient outcomes. The Plan states biofeedback is considered experimental/investigational for all other indications.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient consistent high-quality evidence to support biofeedback in this clinical setting will likely lead to functional improvements. Therefore, without consistent evidence available to support this method of treatment any reported improvements cannot be tied with certainty to the treatments directly. Therefore, this request for biofeedback will be considered not 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for biofeedback training by any modality (CPT code 90901) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 27, 2020.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in laboratory setting. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power elevating leg rests with electronic connection for a power wheelchair (PWC).  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that power elevating leg rests 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that you have a musculoskeletal condition or a cast or brace that prevents 90 degree movement at the knee, significant swelling of the lower extremities, or a reclining back on a wheelchair that requires elevating leg rests. The records show that you have sufficient upper body strength to control any power options through the approved switches. The services are therefore not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve power elevating leg rests with electronic connection for a power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve left breast implant removal.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee previously had breast augmentation. The record indicates that the right implant was removed because of implant failure, was not a cancer surgery, and was approved by the plan to be performed by an out of network provider.  The removal of the left breast implant is to alter or enhance the appearance of a breast that has not undergone a medically reasonable and necessary surgery. The services are therefore not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve left breast implant removal.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70450) provided July 2, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code has a bundled relationship with another code 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 70450 has a bundled relationship with 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 radiology services (70450) provided July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic services (97110, 98942, G0283) provided on June 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says out-of-network services must be pre-authorized.  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 services 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 these services. Therefore, we decided that the Plan does not have to pay for chiropractic services (97110, 98942, G0283) provided on June 18, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an apicoectomy (D3410), and retrograde filling, per
root, (D3430) for tooth # 7.

You asked the Plan to pre-approve the dental services. You say that the endodontist was approved initially.
You say that you cannot afford to pay for the treatment out of pocket. You say that you expected your
insurance to help you. The Plan denied your request. The Plan says apicoectomy is not listed as a covered
service. The Plan says that 1 endodontic treatment per tooth is covered per year. The Plan also says that the
frequency limit has been reached as you already received a root canal for this 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, apicoectomy is not listed as a covered service.
Additionally, the frequency limit for endodontic treatment has been reached. The record shows that you
received a root canal at your previous appointment. Although the visit to the out of network endodontist was
approved, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve an
apicoectomy (D3410), and retrograde filling, per root, (D3430) for tooth # 7.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous implantation of neurostimulator electrode array, epidural services coded 63650 provided on June 9, 2021.

You asked the Plan to pay for the percutaneous implantation of neurostimulator electrode array, epidural 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. 

In this case, the CPT Code Manual definition of code 63650 is percutaneous implantation of neurostimulator electrode array, epidural.

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 the percutaneous implantation of neurostimulator electrode array, epidural services. Our reviewer says that the documentation does not support the services billed. Our reviewer found the documentation did not support that a percutaneous implant of neurostimulator was performed. Therefore, this code cannot be verified by the documentation submitted. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the percutaneous implantation of neurostimulator electrode array, epidural services have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous implantation of neurostimulator electrode array, epidural services coded 63650 provided on June 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy visits.  You asked the Plan to pre-approve additional physical therapy visits. You say that you are requesting sessions to achieve consistency with gait distance. You say that this will allow her to improve quality of life and reduce risk of further functional decline. The Plan denied your request. The Plan says additional physical therapy is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the patient has had extensive prior therapy, has been instructed in a home exercise program in the past and currently shows good safety awareness. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428-HR, A0425-HR) provided on March 7, 2021.    You asked the Plan to pay for the ambulance transportation. You say that these services were necessary. The Plan denied your request. The Plan says this is a duplicate claim. Payment for non-emergent ambulance transportation from the hospital to this enrollee's residence was previously provided for the date in question. The service at issue is a duplicate claim, and there are no medical records to support that the enrollee received this transportation twice on the date in question.  The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Documentation shows that the Plan has paid a previous claim for non-emergent transportation services that brought this enrollee from the hospital to their residence on this date. Medical records were requested to show that the enrollee received this transportation twice on the same day. Supporting documentation was not received. Based on this information, we decided that Medicare rules for coverage of the second ambulance transportation billed on this date have not been met. Therefore, we decided that the Plan does not have to pay for the additional non-emergent ambulance transportation services (A0428-HR, A0425-HR) provided on March 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services you received from May 17, 2021, to June 30, 2021.

You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that you were never advised that there was a copayment for these services. The Plan denied your request. The Plan says you were charged these copayments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for cardiac rehabilitation services.

You have been asked to pay a $40 copayment per visit for the cardiac rehabilitation services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services you received from May 17, 2021, to June 30, 2021.