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

We decided that the Plan does not have to pre-approve Repatha Sure injection.
You asked the Plan to pre-approve the Repatha Sure injection. You say that the requested drug is indicated to reduce the risk of myocardial infarction, stroke, and coronary revascularization in patients with established cardiovascular disease. You say that, based on the FDA-approved indication, the requested drug is medically necessary. The Plan denied your request. The Plan says drugs which are administered at home are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sure injection.
Benefits for the Repatha Sure injection may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on February 2, 2021.

You asked the Plan to pay for the lab services. You say that these labs should be covered. The Plan denied your request. The Plan says the Place of Service reported on the claim is not correct.

Medicare rules say that lab services should be billed with the Place of Service where the specimen was collected from the patient. In this case, you billed with Place of Service 81, which would indicate that the lab itself collected the specimen. However, the medical records show that the patient's specimen was NOT collected at the lab, but by the patient's doctor. The patient's doctor then sent the sample to your lab for processing. Based on Medicare rules, you should have entered the Place of Service where the specimen was collected on the 1500 Claim Form. 

We looked at the file and Medicare rules. 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 lab services provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy provided from January 7, 2021, through April 1, 2021.
You asked the Plan to pay for the massage therapy. You say that medical massage therapy has been the only treatment that has worked to elevate your chronic daily pain as you cannot take opiates anymore as they are highly addictive. The Plan denied your request. The Plan says massage is only covered when performed by a chiropractor.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pay for massage therapy provided from January 7, 2021, through April 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on
May 5, 2020.

You asked the Plan to pay for code 97530. You say that the medical records support the billing of code 97530.
The Plan denied your request. The Plan says the medical records do not support the billing of code 97530.

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 97530 is Therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

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 code 97530. Our reviewer says that the medical records do
not support the billing of code 97530. Our reviewer found the therapy visit documents services were performed
in the enrollee's home by a Certified Occupational Therapist Assistant. CPT code 97530 should not be
reported with a Current Procedural Terminology (CPT) code. A more appropriate code to report for home
services would be a Healthcare Common Procedure Coding System (HCPCS) code. Therefore, CPT code
97530 would not be covered.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 97530 have not been met. Therefore, we decided that the Plan does not
have to pay for the therapy services represented by code 97530 provided on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81407 and 81408) provided on January 19, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81407 and 81408) provided on January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee lives alone. You say that the enrollee has a need for therapy and moderate assist to get out of bed and to walk. You say that the enrollee is medically ready to start therapy. The Plan denied your request. The Plan says the guidelines for coverage of care in an IRF have not been met. The Plan says that the enrollee could receive care in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for acute kidney injury and protein calorie malnutrition. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 7, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroencephalogram (EEG) services represented by code 95724 provided on January 4, 2021.
You asked the Plan to pay for code 95724. You say that the medical records support the billing of code 95724. The Plan denied your request. The Plan says the medical records do not support the billing of code 95724.
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 95724 is Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG).
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 code 95724. Our reviewer says that the medical records do not support the billing of code 95724. Our reviewer found the procedure report documents "Study was from 11:42 am on 1/4/2021 to 23:59 on 1/4/21". CPT 95724 description states "greater than 60 hours, up to 84 hours of EEG recording". Procedure report does not support time required per CPT description, and therefore CPT 95724 would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 95724 have not been met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (EEG) services represented by code 95724 provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic evaluation represented by code 99203 and the spinal x-ray represented by code 72100 provided on May 24, 2021.
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic evaluation represented by code 99203 and the spinal x-ray represented by code 72100 provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a primary care
provider on February 10, 2021.

You asked the Plan to waive the copayment for the primary care visit. You say that you believe this visit was
an annual physical, so there should be no copayment. The Plan denied your request. The Plan says you were
charged this copayment 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 $10
copayment for visits with primary care providers.

You have been asked to pay a $10 copayment for the primary care visit. We reviewed the medical records from
this visit. In addition to the services that are typically part of an annual physical, your doctor also performed an
assessment of your knee arthritis and recommended a referral for physical therapy. In addition, the doctor also
advised you to take magnesium for intermittent leg cramping. These services are outside of the scope of what
is listed in your Evidence of Coverage as being included in the annual physical. That is why the primary care
office visit copayment applies. 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 copayment for the office visit you had
with a primary care provider on February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Capecitabine.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.
Therefore, we decided that the Plan does not have to pre-approve Capecitabine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services represented by codes 27635 and 29897 provided on August 19, 2020.
You asked the Plan to pay for codes 27635 and 29897. You say that the medical records support the billing of codes 27635 and 29897. The Plan denied your request. The Plan says the medical records do not support the billing of codes 27635 and 29897.
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 27635 is Excision or curettage of bone cyst or benign tumor, tibia or fibula. The CPT Code Manual definition of code 29897 is Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited.
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 codes 27635 and 29897. Our reviewer says that the medical records do not support the billing of codes 27635 and 29897. Our reviewer found for CPT 27635 - operative report does not include documentation of a cyst or benign tumor excision. Per report "A curved hemostat was placed underneath this tissue and alongside the tip of the distal fibula. A rongeur was used to perform a partial excision of the distal fibula removing the exostosis. This completed the peroneal brevis and longus tenolysis". Documentation does not support excision of cyst or benign tumor, and therefore, cannot be confirmed as performed. CPT 29897 - operative report documents "extensive debridement was done", however, documentation does not include the details of debridement, to confirm the level of debridement performed. Therefore, CPT 29897 and CPT 27635 would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 27635 and 29897 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services represented by codes 27635 and 29897 provided on August 19,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 00812 provided on July 13, 2020.

You asked the Plan to pay for code 00812. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Medicare says that unconditionally packaged services are identified in the OPPS Addendum B with status indicator of N and these services are not paid separately since payment is included in the APC. CPT code 00812 is identified with a status indicator of N. No separate payment can be made in this case. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 00812 provided on July 13, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that it is felt that SNF care would be appropriate for this enrollee. The Plan denied your request. The Plan says that skilled services can be provided on a less than daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the requested SNF admission is shown to be medically reasonable and necessary. Our physician reviewer found the beneficiary is a male with orthostatic hypotension and syncope. From a nursing perspective, the beneficiary received oral medications. He had continued orthostasis. He had a new Foley catheter placed. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the acute hospital. The beneficiary was at standby assist to contact guard assist level with transfers and bed mobility and he was unable to ambulate due to low blood pressure. The beneficiary required varying assist with daily living activities. There are identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary does require skilled nursing or therapy services on a daily basis. This beneficiary does meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 dental tooth extractions (D7140), bone replacement graft (D7953), and sedation (D9222 and D9223) provided on January 13, 2021.
You asked the Plan to pay for dental services. You say that these services were the result of a medical procedure and were part of surgery to repair a Zenkers diverticulum. The Plan denied your request. The Plan says these denial of payment for these services is correct, because these services are not covered by the Plan's dental 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 pay for dental tooth extractions (D7140), bone replacement graft (D7953), and sedation (D9222 and D9223) provided on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services represented by codes 44500 and 30999
provided on March 19, 2021.
You asked the Plan to pay for codes 44500 and 30999. You say that the medical records support the billing of
codes 44500 and 30999. The Plan denied your request. The Plan says the medical records do not support the
billing of codes 44500 and 30999.
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 44500 is Introduction of long gastrointestinal tube (eg,
Miller-Abbott) (separate procedure). The CPT Code Manual definition of code 30999 is Unlisted procedure,
nose.
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 codes 44500 and 30999. Our reviewer says that the medical
records do not support the billing of codes 44500 and 30999. Our reviewer found procedure report documents a
simple nasalgastric tube placement, ending in the stomach. CPT 44500 should be reported for long
gastrointestinal tube placement in the small intestine. Radiology report confirms placement in stomach.
Therefore, CPT 44500 would not be covered. CPT 30999 is not supported as a separate procedure by the
documentation. Placement of a septal strap to keep NG tube secure, and would not be separately reported, as it
is typically a component of a more complex service. Therefore, CPT 30999 would not be covered separately.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of codes 44500 and 30999 have not been met. Therefore, we decided that the Plan
does not have to pay for the surgical services represented by codes 44500 and 30999 provided on March 19,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986).

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee was previously provided with the same item, and the requested item is for use outside of the home.

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 a push-rim activated power assist system (E0986).