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

We decided that the Plan does not have to pay for CPT codes 22633 and 22840 provided on June 24, 2019.
You asked the Plan to pay for CPT codes 22633 and 22840. You say that the medical records support the billing of CPT codes 22633 and 22840. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 22633 and 22840.
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 22633 is Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar, and the definition of code 22840 is Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure). 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 CPT codes 22633 and 22840. Our reviewer says that the medical records do not support the billing of CPT codes 22633 and 22840. Our physician reviewer found National Correct Coding Initiative (NCCI) Policy Manual, chapter I states: Physicians must report services correctly. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. CPT code 22633 is not supported by the medical record. The documentation does not contain evidence that spinal fusion by a posterior or posterolateral technique was performed during this episode of care. CPT code 22840 is not supported by the medical record. The documentation does not contain evidence that posterior non-segmental instrumentation was performed during this episode of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 22633 and 22840 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 22633 and 22840 provided on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs long term acute care.
The Plan denied your request. The Plan says long term acute care can be provided in the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. In this case, ongoing care needs include surveillance laboratory studies, sacral wound vacuum
care with dressing changes, intravenous antibiotics, oral analgesia, and therapy services. The documentation
does not support that the enrollee in this case requires services at the LTACH that are not available at the acute
care hospital where he is currently receiving care. Consequently, the requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have multiple sclerosis and that without a bath chair you have already fallen twice in the shower. You say that not having the chair is putting your health in jeopardy. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on August 5, 2019.
You asked the Plan to pay for the drug testing. 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. We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician). Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and garment to use with pneumatic compression device (E0667).
You asked the Plan to pay for a pneumatic compression device and garment. You say that please see enclosed documentation supporting medical necessity and coverage under the national coverage determination. The Plan denied your request. The Plan says the enrollee does not meet the criteria as there was no four week trial of an E0650 or E0651 as required. E0667 is also non-covered when requested in conjunction with the non-approved code E0652.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652) and garment to use with pneumatic compression device (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture rendered to you on September 2, 2019.
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 are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture rendered to you on September 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 82803, 83880, 85025,
85651, 86038, 86140, 86735, 86762, 86833, and 86832 provided on September 26, 2018.
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 billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 80053, 82803, 83880, 85025, 85651, 86038, 86140, 86735, 86762, 86833, and 86832
are not supported in the medical record. Specifically, the laboratory services billed have a professional
component/technical component indicator of 9. The laboratory services billed may not be paid as the concept of
the PC/TC does not apply, and modifiers 26 and TC cannot be used with these codes. Based on this
information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053, 82803,
83880, 85025, 85651, 86038, 86140, 86735, 86762, 86833, and 86832 provided on September 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Diabetic Testing Supplies (A4253, A4259, A4256, A4235) provided August 20, 2019 to November 8, 2019.You asked the Plan to pay forthe Diabetic testing supplies. You say that the items were medically necessary.The Plan denied your request. The Plan says the included proof of delivery is not valid.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the provided proof of delivery did not contain any order or tracking number to verify shipment.Therefore, we decided that the Plan does not have to pay forDiabetic Testing Supplies (A4253, A4259, A4256, A4235) provided August 20, 2019 to November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic mammogram and the ultrasound provided on September 19, 2019.
You asked the Plan to waive the copayments for the diagnostic mammogram and ultrasound. You say that you were told that the codes used were covered codes and you would have no out-of-pocket costs. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $40 copayment for each basic imaging service (e.g., general x-rays or ultrasounds). You have been asked to pay a $40 copayment for the diagnostic mammogram and a $40 copayment for the ultrasound. The diagnostic mammogram and ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received a screening mammogram on September 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided on August 7, 2019
by out of network provider.
You asked the Plan to pay for skilled nursing facility services. You say that the provider depends upon the
hospital staff to verify eligibility and to obtain proper authorization from the patient's insurance company. The
Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's
primary care physician, did not refer these services.
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 has network providers
available who can provide 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 skilled nursing facility services provided on
August 7, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpatient supervision (99339) provided on May 6, 2019.You asked the Plan to pay forpatient supervision. You say that this was a medically necessary service and should be paid.The Plandenied your request. The Plan says medical records were not received.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of patient supervision have not been met. Specifically, no medical records were received to corroborate the billed service.Sufficient information has not been provided to show whetherMedicare coverage criteria have been met.Therefore, we decided that the Plan does not have to pay forpatient supervision (99339) provided on May 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for PT from May 1, 2019 to May 14, 2019.You asked the Plan to waive the deductible forPT. You say that you were told that the provider was in-network.The Plan denied your request. The Plan says the claims were processed correctly and A. Denton is being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The contract with the Plan says that there is a $1,250 deductible for out-of-network services. The contract with the plan also says that after the $1,250 deductible has been met, enrollee's must pay 30% coinsurance for out-of-network outpatientrehabilitation services. The enrolleereceived PT from an out-of-network provider from May 1, 2019 to May 14, 2019. Therefore, the enrollee is responsible to pay their share of the out-of-network cost-sharing charges. The record shows that the enrollee only paid $136.23 toward the deductible. Therefore, the enrollee is responsible to pay the total allowed amount of $635.77.The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,250 deductible for out-of-network outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time PT wasreceived on May 1, 2019 to May 14, 2019.Therefore, we decided that the Plan does not have to waive the deductible forPT  from May 1, 2019 to May 14, 2019.
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 you believe that care in an IRF is the best option.The Plan denied your request. The Plan says the enrollee does not have any complex medical needs which require the availability of a rehabilitation physician on a 24/7 basis or face to face supervision by an inpatient rehabilitation physician 3 times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly MODERATE to MIN assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 23, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. 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 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 physician's services provided on September 23, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBeovu 6mg/0.05ml vial.You asked the Plan to pre-approveBeovu 6mg/0.05ml vial. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Beovu 6mg/0.05ml vial. Our reviewer says that the medication is not medically necessary. Our physician reviewer found thedocumentation does not support that Bevacizumab would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Beovu 6mg/0.05ml vial have not been met.Therefore, we decided that the Plan does not have to pre-approveBeovu 6mg/0.05ml vial.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One injections.
You asked the Plan to pre-approve the Synvisc One. You say that you do not use Orthovisc or Monovisc in this
office due to the cost/reimbursement for these drugs. You feel that the Plan should cover the drug that you wish
to use. The Plan denied your request. The Plan says there is no medical reason that the requested drug is needed
over the preferred agents.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Synvisc One. Our reviewer says that
the requested drug is not considered medically reasonable and necessary based on step therapy rules. Our
physician reviewer found this appeal considers the request for Synvisc One for the treatment of osteoarthritis in
bilateral knees. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc.
Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline
contraindications or reasons these medications were not considered. Without the support of the documentation,
Synvisc One is not approved as step criteria are not met.

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 Synvisc One have not been met. Therefore, we decided that the Plan does
not have to pre-approve Synvisc One injections.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hematoma incision and drainage for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that Entity this procedure is not compatible with the diagnosis.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there was ample suspicion for abscess which could have been a potential medical emergency to warrant drainage. The enrollee was in a position where getting in-network care could have brought a substantial degree of morbidity. 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 pre-approve hematoma incision and drainage for the enrollee.