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

We decided that the Plan has to pay for computerized ophthalmic diagnostic imaging (92133), eye refraction
(92015) and office visit (99204) provided on September 21, 2020.

You asked the Plan to pay for the ophthalmic visit and services. You say that your primary care provider
directed you to the provider in question. You are confused by this denial. The Plan denied your request. The
Plan says that their records show that an approved authorization exists, however either the service performed,
the servicing provider, or the number of visits billed do not match what was approved on the authorization.
Therefore, these services cannot be covered.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward
to the IRE information regarding its decision to deny coverage or payment. The Plan follows these rules.

You were referred for ophthalmic services by a contract provider. The file does not show that the Plan provided
notice that the ophthalmic services would not be covered. Under Medicare rules, this means the ophthalmic
services is considered approved by the Plan. In addition, the Plan has not made reasonable and diligent efforts
to gather and forward to us information regarding their decision to deny your request. The Plan's denial
mentions that there was an approved authorization on file and that some aspect of this approval was not met.
The exact reason for what did not match the approved authorization is unclear. This authorization was not
included in the case file for review. The Plan denial is not substantiated based on the information provided for
review. Therefore, we decided that the Plan has to pay for computerized ophthalmic diagnostic imaging
(92133), eye refraction (92015) and office visit (99204) provided on September 21, 2020.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or nursing services.

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. 

Continued SNF services beyond May 2, 2021, were requested. 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 continued services. Our physician reviewer found that the enrollee no longer qualifies for SNF coverage. He does not have documented skilled nursing needs. His wounds are chronic and the dressing care simple. He does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You require physical and occupational therapy services; however, you do not require an intensive inpatient rehabilitation therapy program. Additionally, there is no documentation provided that indicates you require an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for PET/CT scan of the skull base to mid-thigh provided to the enrollee on November 23, 2020.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the listed diagnosis code is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 pay for the services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found in this case, the record indicates that the enrollee has had scans in May and November 2020. According to the available documentation, the requested test would be the third PET scan for malignant neoplasm of the esophagus. The elements of the coverage rule are satisfied. 

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 been met. Therefore, we decided that the Plan has to pay for PET/CT scan of the skull base to mid-thigh provided to the enrollee on November 23, 2020.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 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 procedure codes 27134 and 26992.

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 27134 is revision of total hip arthroplasty; both components, with or without autograft or allograft. The definition of code 26992 is incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess). 

We find that CPT codes 27134 and 26992 are not supported in the medical record. Specifically, there is no documentation of a revision of total hip arthroplasty for both components to support code 27134. There is no documentation of an incision of the bone cortex to support code 26992. 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 surgical services rendered on October 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a skin substitute (15271 and 15272) provided on September 30, 2020.

You asked the Plan to pay for the application of a skin substitute. 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 services 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 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 application of a skin substitute. Our reviewer says that CPT codes 15271 and 15272 do not meet criteria for billing or reimbursement consideration. Our reviewer found The medical records provided do not include sufficient documentation to validate that an application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area or an application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) was performed on September 30, 2020, therefore these services cannot be verified. 

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 application of a skin substitute have not been met. Therefore, we decided that the Plan does not have to pay for the application of a skin substitute (15271 and 15272) provided on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer (14020) provided on June 19, 2020.
You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 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. 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 adjacent tissue transfer. Our reviewer says that CPT code 14020 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to verify an Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less was performed on June 19, 2020, therefore this service cannot be verified. 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 adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14020) provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee
on April 25, 2020.

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 records do 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 99291 is "Critical care, evaluation and management of
the critically ill or critically injures patient, first 30-74 minutes."

We asked our coding 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
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical
records provided do not include documentation of time spent providing critical care services for April 25, 2020,
therefore this service cannot be verified.

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 services have not been met. Therefore, we decided that the Plan does not
have to pay for critical care services (CPT 99291) provided to the enrollee on April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for an injection for the enrollee.

You asked the Plan to pre-approve the anesthesia. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation to support the need for anesthesia for this procedure.

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 anesthesia. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a specific indication is needed for a separate anesthesia provider. At this point, there is insufficient documentation to support a separate anesthesia provider.

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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for an injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 26, 2020 by a non-network provider.

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 services were rendered by a non-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 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 laboratory services provided on October 26, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) and knee orthoses (L1833 and L2397) provided on June 25, 2020.
You asked the Plan to pay for the back and knee orthoses. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the ordering physician and the member.
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 back and knee orthoses. Our reviewer says that the LCD L33790 criteria have not been met for an L0650 orthosis. The documentation does not reveal an objective hands on detailed physical examination of the lumbar spine or the neuromuscular system. There is no evidence on a physical exam that indicates patient's pain is reduced by restricting trunk mobility. There is no evidence of a recent injury or surgery to the spine or related soft tissues that requires the orthosis to facilitate healing. There is no evidence on an objective physical exam of weak or deformed spinal muscles. The requested L0650 lumbosacral orthosis is not medically necessary. Our physician reviewer found the requested L1833 and L2397 are not medically necessary per LCD L33318. There is no evidence of a detailed properly performed neuromuscular examination or gait evaluation. There is no evidence of true instability. The "objective of assessment" does not indicate laterality of the pivot shift or laxity pivot test and there is no indication that there is pathological laxity with objective measurements of any laxity. There is no evidence of a recent surgery or injury to the knee. There is no evidence of a gait evaluation or indication the patient is current ambulatory and requires the requested knee braces. 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 back and knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) and knee orthoses (L1833 and L2397) provided on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reline for a complete upper denture (D5750) and a
reline for a complete lower denture (D5751).
You asked the Plan to pre-approve the dental services. You say that if you had your original teeth, these
services would be covered. You also say that you think your dentist called about replacing tooth before you
went. The Plan denied your request. The Plan says the requested services are not listed as covered.
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 a
reline for a complete upper denture (D5750) and a reline for a complete lower denture (D5751).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation (97161) provided on January 23, 2020.
You asked the Plan to pay for the physical therapy evaluation. 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. 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 physical therapy evaluation. Our reviewer says that CPT code 97161 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that a Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family was performed on January 23, 2020, therefore this service cannot be verified. 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 physical therapy evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation (97161) provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider from November 25, 2020, through December 18, 2020.
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 subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider from November 25, 2020, through December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140) and the
periapical x-ray (D0220) provided on December 1, 2020.
You asked the Plan to pay the full amount for the dental services. You say that these services should be
covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service.
The Plan says 1 periapical x-ray is covered per calendar year with a 50% coinsurance when performed out of
network. The Plan says if you see an out of network dentist, the coinsurance level will apply to the average
negotiated INFS (in network fee schedule) in your area. The Plan also says that you are responsible for the
difference between the INFS and dentists' charged fees when visiting an out of network dentist.
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 limited oral evaluation is not
among those covered under this benefit. When you see an out of network dentist, the coinsurance level will
apply to the average negotiated INFS in your area. The record shows that the periapical x-ray was paid at the
INFS rate with the coinsurance applied. Therefore, we decided that the Plan does not have to pay the full
amount for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on December 1,
2020.