Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 21, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the provider prescribed the orthosis without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
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 lumbar-sacral orthosis (L0650). Our
reviewer says that the orthosis is not medically reasonable and necessary. Our physician reviewer found the
available documentation in the case file does not support that the lumbar-sacral orthosis was medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. An appropriate history and a physical examination of the back would reasonably be required to
adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation
does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in
this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient
documentation of a credible physical examination of the back.
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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided
that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on March 12, 2021.
You asked the Plan to pay for the dental service. You say that you have not gone to see any other doctors or dentists these last months. The Plan denied your request. The Plan says panoramic x-rays are covered once every 3 years. The Plan also says that the frequency limit has been exceeded.
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, panoramic x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on March 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's required services cannot be met at a lower level of care. The Plan denied your request. The Plan says the enrollee can safely receive the services 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 physician reviewer found that the enrollee has a past medical history of diabetes, hypertension and dementia and is living at home with weakness and increased episodes of falling. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehab therapy program. She does require physical and occupational therapy but there is no documented need for an intensive rehab program.
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: 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 records provided support the need for LTACH care. The Plan denied your request. The Plan says the criteria for coverage have not been met. The Plan says that the enrollee can continue to get care at the current hospital until he is ready for discharge to a lower level of care.
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 the enrollee was admitted to the current acute care hospital with acute on chronic respiratory failure related to pulmonary fibrosis and fluid overload, treated with oxygen and diuresis. The plan is to use home oxygen. A palliative care consultation was requested. The enrollee appears to be improving, is more stable, and only requires short-term additional acute care services which can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and
covered at the current facility. Transfer to a lower level of care, such as home with home oxygen and palliative
services, may be considered when treatment has completed.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transport rendered on March 21, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that ambulance claims must be billed with the QM or QN modifier to describe whether the service was provided under arrangement or directly. We looked at the file and Medicare rules. The file shows that the services were not billed with the required QM or QN modifier. 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 air ambulance transport rendered on March 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99214) provided January 6, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was missing a required modifier and cannot be paid as 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 find that CPT code 99214 is not supported in the medical record. Specifically, the claim did not include a required 95 modifier for the place of service listed (12, home).
Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99214) provided January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on July 24, 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 01630 is 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 01630 is anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified.
We find that CPT code 01630 is not supported in the medical record. Specifically, there is no anesthesia report
in the submitted documentation. 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 anesthesia
services rendered on July 24, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on November 11, 2020, and November 25, 2020 billed with code Q4038.
You asked the Plan to pay for the outpatient hospital services as billed. You say that the services were medically necessary and should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The code Q4038 has a status indicator of "B" in the Outpatient Prospective Payment System (OPPS). This means that the code is not recognized when submitted on an outpatient hospital Part B type of bill. OPPS
claims are denied when invalid coding is used. A corrected claim may be submitted. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on November 11, 2020, and November 25, 2020 billed with code Q4038.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is lacking a need for this level of intensity of medical or therapy.
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 a stroke. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no documentation to show why an optimally configured manual wheelchair
cannot be used, or why the enrollee's caregivers cannot adequately propel such a manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the
documentation is very conflicting on your mobility status. The physician documentation indicates normal gait,
yet wheelchair bound as well as poor insight and judgement on November 24, 2020, and then good insight and
judgement on May 13, 2021. The documentation is not clear as to why your caregivers are unable to assist with
operating a manual wheelchair in the home, as you are not noted to be safe with operating a power wheelchair.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided January 29, 2021.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was billed with an invalid place of service.
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 code 99153 is not supported in the medical record. Specifically, CPT code 99153 has a PC/TC indicator of 3. This code can only be reported in the inpatient setting. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met.
Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a metallic inlay (D2530), provided on January 26, 2021.

You asked the Plan to pay for a metallic inlay. You say that the service should be covered. The Plan denied
your request. The Plan says the service is not a covered benefit.

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 a metallic
inlay (D2530), provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 11, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a REVO adjustable volume socket.
You asked the Plan to pre-approve the socket. You say that this is needed to be able to accommodate residual limb volume change. The Plan denied your request. The Plan says the requested socket does not have FDA approval, and is considered experimental and 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 the socket. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested item is not FDA approved and therefore not proven safe and effective for your 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 the socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a REVO adjustable volume socket.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on April 1, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you were not aware this service
would cost this much, and you cannot afford the copayment. The Plan denied your request. The Plan says the
copayment applied 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 $100 per
day for a Medicare-covered ultrasound.

You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient
diagnostic tests and therapeutic services and 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
copayment for the ultrasound provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 19, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT 99231) provided to the
enrollee on February 9, 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 a corrected claim has not been received.

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 99231 is "subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of the 3 key components: A problem focused
interval history; A problem focused examination; Medical decision making that is straightforward or of low
complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent
with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable,
recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital
floor or unit."

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 modifier 59
is used to identify procedures/services, other than evaluation and management services, that are not normally
reported together, but are appropriate under the circumstances. The documentation does not support the use of
modifier 59, and therefore was reported incorrectly and not 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 the services have not been met. Therefore, we decided that the Plan does not
have to pay for subsequent hospital care (CPT 99231) provided to the enrollee on February 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit represented by code 99283
provided on January 25, 2021.
You asked the Plan to pay for code 99283. 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.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99283
has a bundled relationship with code 99284 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the emergency department visit represented by code 99283 provided on
January 25, 2021.