Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (HCPCS G0151, G0299, Q5001) provided to the enrollee from July 2, 2020 to August 9, 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 an incorrect date of service was 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 the denied codes is: 

HCPCS G0151: 

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes 

HCPCS G0299: 

Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes 

HCPCS Q5001: 

Hospice or home health care provided in patient's home/residence 

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 provider did not meet Medicare guidelines state prior to January 1, 2020, plan of care is paid based on a 60-day episode and after January 1, 2020 is based on a 30-day episode. In this case, the provider did not follow CMS guidelines for billing. The billing period ranged from July 2, 2020 through August 9, 2020 which does not meet guidelines effective after January 1, 2020.

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 home health services (HCPCS G0151, G0299, Q5001) provided to the enrollee from July 2, 2020 to August 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 20, 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 64495, 99152, and 99153 are 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 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). The definition of code 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. The definition of code 99153 is moderate sedation services by physician also performing a procedure, additional 15 minutes.

We find that CPT codes 64495, 99152, and 99153 are not supported in the medical record. Specifically, the operative report does not include documentation of injection(s) of a diagnostic or therapeutic agent into the lumbar or sacral paravertebral facet joint with image guidance to support code 64495. There is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status to support codes 99152 and 99153. 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 July 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high intensity focused ultrasound (HIFU).
You asked the Plan to pre-approve a HIFU. You say that the requested HIFU is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested HIFU.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a HIFU. Our reviewer says that the enrollee does not meet criteria for the requested HIFU. Our physician reviewer found high intensity focused ultrasound (HIFU) uses sonic waves to create thermal energy that destroys the target tissue within the prostate. HIFU has not been compared with other standard treatment approaches in randomized trials, nor is it included in guidelines for the initial management of men with prostate cancer. Clinicians should inform patients considering HIFU that this treatment option lacks robust evidence of efficacy, and that even though HIFU is approved by the US Food and Drug Administration (FDA) for destruction of prostate tissue, it is not approved explicitly for the treatment of prostate cancer. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a HIFU have not been met. Therefore, we decided that the Plan does not have to pre-approve a high intensity focused ultrasound (HIFU).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan 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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not 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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).

You asked the Plan to pre-approve personal care services. You say that you would like to appeal this service. The Plan denied your request. The Plan says the requested service is custodial in nature, and without medical records your provider has not shown that you have non-custodial needs.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you ask that the plan consider the healthcare team's clinical judgment regarding the original prescription of this medically necessary device for the enrollee and reverse the denial so she may begin receiving treatments prescribed The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

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 pre-approve a pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services described by current procedural terminology (CPT) code 80307 provided on July 7, 2020.

You asked the Plan to pay for CPT code 80307. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records provided do not support the billing of CPT code 80307.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. In this case, insufficient records were submitted for review. The billed service cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory services described by current procedural terminology (CPT) code 80307 provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the brain.

You asked the Plan to pre-approve MRI scan of the brain. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pre-approve MRI scan of the brain. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has back pain and bladder and bowel incontinence. A neurologic examination does not indicate evidence of intracranial pathology. The medical record does not indicate a medically necessary or reasonable rationale for the MRI of the brain. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional chiropractic visits.

You asked the Plan to pre-approve the additional chiropractic visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

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 plan provides a supplemental chiropractic benefit that is limited to 6 visits a year. 

The records show that the service at issue is not manual manipulation of the spine. It is not covered by Medicare. The plan's supplemental benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 6 additional chiropractic visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio (Q5101).

You asked the Plan to pre-approve Zarxio. The Plan denied your request. The Plan says Zarxio (Q5101) is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Zarxio. Our reviewer says that Zarxio (Q5101) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee is being treated with Folinic acid, Fluorouracil, and Irinotecan (FOLFIRI) plus Avastin for metastatic colorectal cancer. Our reviewer found that the risk of febrile neutropenia is less than 10%. The elements of the coverage rule are not satisfied. Our physician reviewer also found that the requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio (Q5101).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network
provider.

You asked the Plan to pre-approve the physical therapy to be provided by the out-of-network provider. The
Plan denied your request. The Plan says the provider you requested is not part of your primary care physician's
network. You must receive your care from a network provider. In most cases, care you receive from anonnetwork
provider (a provider who is not part of our plan's network) will not be covered.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical
therapy to be provided by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravitreal injection provided on December 29, 2020.
You asked the Plan to waive the copayment for the intravitreal injection of a pharmacologic agent (67028). You say that the procedure only takes half an hour so you shouldn't have to pay $250. 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 $250 copayment for Outpatient Surgery. You have been asked to pay a $250 copayment for the intravitreal injection of a pharmacologic agent (67028). The intravitreal injection of a pharmacologic agent (67028) falls within the Outpatient Surgery 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 intravitreal injection provided on December 29, 2020.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgery to treat an incarcerated hernia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee walker (E0118).
You asked the Plan to pre-approve a knee walker. You say that you are having surgery and will need this
scooter. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch
substitutes (E0118).
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical
equipment in the State of Florida has decided that the knee walker coded as E0118 is not medically reasonable
and necessary. Based on this information, we decided that Medicare rules for coverage of a knee walker have
not been met. Therefore, we decided that the Plan does not have to pre-approve a knee walker (E0118).
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 can easily fall in the shower which is a
danger to you. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hyperbaric oxygen therapy services described by current procedural terminology (CPT) codes G0277 and 99183 provided on September 3, 2020.

You asked the Plan to pay for CPT codes G0277 and 99183. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes G0277 and 99183.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. In this case, the medical records provided were insufficient to verify if the correct codes were submitted for payment. Therefore, we decided that the Plan does not have to pay for the hyperbaric oxygen therapy services described by current procedural terminology (CPT) codes G0277 and 99183 provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of impacted tooth (D7230) provided on November 19, 2020.
You asked the Plan to pay for removal of impacted tooth. You say that you were told by the provider that the service at issue would be covered at 50%. The Plan denied your request. The Plan says the service at issue 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 removal of impacted tooth (D7230) provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses.

You asked the Plan to pre-approve the eyeglasses. The Plan denied your request. The Plan says you previously received routine eyewear on June 26, 2019 and you are not eligible for coverage for routine eyewear until
June 26, 2021.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years.

We looked at the file and the Plan's rules. The file shows that you received the routine eyewear benefit on
June 26, 2019 and you will not be eligible to receive the routine eyewear benefit until June 26, 2021 because the Plan coverage is every two years. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses.