Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and endodontic therapy (D3320) provided on September 2, 2021, and September 13, 2021.
You asked the Plan to pay for the crown and endodontic therapy. You say that you pay your premiums and have never had a problem. You also say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you were not enrolled in the Platinum Dental Rider on these dates of 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. Therefore, we decided that the Plan does not have to pay for the crown
(D2740) and endodontic therapy (D3320) provided on September 2, 2021, and September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical supplies and devices (0270) provided August 1, 2021.
You asked the Plan to pay for the medical supplies and devices. You say that this claim was denied due to the facility submitting a false code and also changing the bill from $319.30 to $421.60. The Plan denied your request. The Plan says the provider submitted these services as verification of non-covered services
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 0270 is Medical/Surgical Supplies and Devices. We find that CPT code 0270 is not supported in the medical record. Specifically, the claim was billed with bill type 220 which indicates it is a non-payment/zero claim as well as condition code 21. A corrected claim is required in order to proceed with claim processing for payment. Based on this information, we decided that Medicare rules for coverage of the medical supplies and devices have not been met. Therefore, we decided that the Plan does not have to pay for the medical supplies and devices (0270) provided August 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 13, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the periodontal maintenance. You say that your usual dentist did not have a
hygienist to provide the periodontal cleaning that you need three times per year. You also say that this service
is covered under your insurance. The Plan denied your request. The Plan says these services were rendered by a
provider who has opted out of Medicare. The Plan also says that the service rendered does not fall into the
category of emergency care services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodontal maintenance (D4910) provided on August 13, 2021 by a
Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from April 16, 2020, to August 10, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you returned the equipment and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 20% coinsurance for DME and related supplies. The record shows that you received DME and related supplies from April 16, 2020, to August 10, 2020, for a total of 3 months. The total allowed amount per each month is $816 and 20% of that is $163.20. The total
amount you owe is: $163.20 (coinsurance) x 3 (months) = $489.60. You have been asked to pay the total coinsurance amount of $489.60 for DME and related supplies. DME and related supplies fall within the DME and related supplies benefit category. 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 coinsurance for DME and related supplies provided from April 16, 2020, to August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device and supplies provided on August 9, 2021.
You asked the Plan to pay for a CPAP device and supplies. You say that your prior CPAP was recalled by the manufacturer due to cancer-causing components in the machine and that your only option was to purchase a new machine. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the items at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a CPAP device and supplies provided on August 9, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that the services 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 Facet Joint Interventions 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 facet joint injections. Our reviewer says
that the services are not medically necessary. Our physician reviewer found per the coverage criteria, facet
injections are indicated for the treatment of chronic low back pain in the absence of untreated radiculopathy or
neurogenic claudication. The review has determined that the enrollee does not meet the coverage criteria
detailed in the LCD.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
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 by Medicare.
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 current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition as discussed above. FDA indications include implantation of the Superion device at one or two
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA
indicated levels of "moderate" spinal stenosis (including the planned level of implantation of L3-4.).
FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been
adequately addressed in the medical records. There is imaging evidence of approximately 2mm of
anterolisthesis of L3 on L4 in the neutral and flexed positions, reducing to normal alignment in the extended
position. There is also imaging evidence of moderate levoconvex scoliosis centered at L2, with no
documentation of the Cobb angle. There is no compelling rationale presented or extenuating circumstances
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for
Vertiflex Superion interspinous device at L3-L4 is 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 25, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the service at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is not endorsed by two learned Orthopedic societies. The procedure is still considered experimental/investigational. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0482) provided to the enrollee on January 20, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code remains not supported
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 G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."
We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 drug testing services (G0482)
provided to the enrollee on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from June 7, 2020 to June 18, 2020.
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 DRG is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 870 (SEPTICEMIA OR SEVERE SEPSIS
WITH MV >96 HOURS), principal diagnosis A41.9 (sepsis, unspecified organism) and secondary diagnosis
R65.21 (severe sepsis with septic shock).. 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
these services. Our reviewer says that the submitted records do not support the billing of DRG 870, principal
diagnosis A41.9, and secondary diagnosis R65.21. Our physician reviewer found the records support an
admission for gastrointestinal hemorrhage but are inconsistent regarding a diagnosis of sepsis with septic
shock. There is no supporting documentation in the medical records for this diagnosis. The enrollee was
admitted with gastrointestinal bleeding and reported dark stools. No suspected or confirmed source of infection
was reported by an attending provider. Therefore, no evidence of a systemic, life-threatening organ dysfunction
due to a dysregulated host response to infection, defining sepsis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from June 7, 2020 to June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99350) rendered by the out-of-network (OON) provider on August 17, 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 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 home visit for the evaluation and management of an established patient (99350)
rendered by the out-of-network (OON) provider on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87541, 87581, 87640, 
87651, 87798 and 87632 provided on August 31, 2020.

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 provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 87486, 87541, 87581, 87640, 87651, 87798 and 87632 provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis, 
initial, up to 1 hour (specify substance or drug) (96365) intravenous infusion, for therapy, prophylaxis, or 
diagnosis, each additional hour (96366) concurrent infusion (96368) therapeutic Drug Assays (80202) 
ertapenem sodium injection, 500 mg (J1335) vancomycin hcl injection, 500 mg (J3370) collection of blood 
specimen using established central or peripheral venous catheter (36592) provided on August 24, 2021 by an 
out-of-network (OON) provider.

You asked the Plan to pay for the infusion service. You say that the following information is being submitted to 
support medical necessity. Please review the enclosed documents and reprocess this claim. The Plan denied 
your request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered.

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 intravenous infusion, for therapy, prophylaxis, or 
diagnosis, initial, up to 1 hour (specify substance or drug) (96365) intravenous infusion, for therapy, 
prophylaxis, or diagnosis, each additional hour (96366) concurrent infusion (96368) therapeutic Drug Assays 
(80202) ertapenem sodium injection, 500 mg (J1335) vancomycin hcl injection, 500 mg (J3370) collection of 
blood specimen using established central or peripheral venous catheter (36592) provided on August 24, 2021 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on April 12, 2021.

You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. 

We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not support that more than 30 minutes of discharge day management services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on April 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on August 6, 2020.

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 procedure code 97110 is not supported.

The Plan must follow Medicare rules. Medicare rules say that p
roviders must report services correctly. 
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting 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. Therefore, 
we decided that the Plan does not have to pay for the physical therapy services rendered on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and fundus photography provided on August 7, 
2021.

You asked the Plan to pay for the eye exam and fundus photography. You say that you had a change in vision 
post cataract surgery. You say that this is the reason you sought routine services prior to the annual date. The 
Plan denied your request. The Plan says payment cannot be issued for services received from a provider who 
has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the eye 
exam and fundus photography provided on August 7, 2021.