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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on November 11, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe an exception should be made, and this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, problem focused limited oral evaluation (D0140) and is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on October 28, 2020 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on October 15, 2020.

You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. 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 S1015 and S8301 are not supported in the medical record. Specifically,these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have not been met.Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression wraps (A6545).

You asked the Plan to pre-approve gradient compression wraps. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression wrap described by code A6545 is only covered when it is used in the treatment of an open venous stasis ulcer that meets the qualifying wound requirements.

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 gradient compression wraps. Our reviewer says that the items are not medically necessary. Our physician reviewer found a gradient compression stocking is not medically necessary as there is no evidence of an open venous stasis ulcer that meets the qualifying wound requirements.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gradient compression wraps have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression wraps (A6545).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic risk assessment panel provided on November 5, 2020.
You asked the Plan to pay for the genetic risk panel. You say that this was medically necessary and must be paid. The Plan denied your request. The Plan says Medicare does not cover any cardiovascular risk panels other than the basic lipid panel.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information in the record to confirm that coverage criteria are met. The records submitted in this file are not contemporaneous to the testing at issue. The only progress note from the ordering physician is a visit from February 2, 2021, months after the testing was performed. This note does not make any mention of this testing or how it was used. There is no evidence that the enrollee was evaluated prior to this testing or that it was required in order to guide treatment. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic risk assessment panel provided on November 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing visits three (3) or more times weekly.

You asked the Plan to pre-approve the services. You say that you need nursing services more than once a week. The Plan denied your request. The Plan says the requested skilled nursing visits three or more times weekly does not appear to be medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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. physician reviewer found in order to require home health care skilled services, you must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician. Additionally, you must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound means leaving home is a major effort. Our physician reviewer found the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require daily skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Additional skilled nursing visits are not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing visits three (3) or more times weekly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 4, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services. 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 laboratory services provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home injectable therapy provided on August 28, 2020.

You asked the Plan to pay for home injectable therapy (S9542). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes.

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 S9542 is Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

We find that CPT code S9542 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided that the Plan does not have to pay for home injectable therapy provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina injection provided on September 8, 2020.

You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection (J0585). You say that you paid for your medication and had it sent directly to the provider. The Plan denied your request. The Plan says the claims processed correctly with a 20% coinsurance for the drug.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication was dispensed by a pharmacy and was brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina injection provided on September 8, 2020.

Benefits for the onabotulinumtoxina injection (J0585) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power operated vehicle.
You asked the Plan to pre-approve a group 1 power operated vehicle. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 a group 1 power operated vehicle. Our reviewer says that the item is not medically necessary. Our physician reviewer found you have a personal mobility deficit that impairs participation in MRADLs. The documentation indicates that you are able to adequately propel a manual wheelchair. While you can safely operate a PMD in the home the documentation does not support that the Group 1 power operated vehicle is 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 group 1 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power operated vehicle.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 25, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for the continuation of SNF care have 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 73-year-old female with a medical history including chronic lung disease and obesity who was admitted to the hospital after a fall during which you sustained a right femur fracture. You had surgical fixation and were discharged to a skilled nursing facility on March 12, 2021, for inpatient rehab services. As of April 25, 2021, you did not require any skilled nursing or rehab services on a daily basis. Your function had plateaued by April 25, 2021 and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and she could be discharged to a lower level of care for further services. You no longer required skilled nursing services as your needs are custodial.

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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a replacement prosthesis to be provided by an OON provider. You say that the items are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these items. Therefore, coverage criteria have not been met.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 physical therapy home health visits, 6 occupational therapy home health visits, and 3 skilled nursing home health visits.

You asked the Plan to pre-approve 8 physical therapy home health visits, 6 occupational therapy home health visits, and 3 skilled nursing home health visits. You say that you believe the sessions in question were just beginning to help you. The Plan denied your request. The Plan says rules for home health services have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 8 physical therapy home health visits, 6 occupational therapy home health visits, and 3 skilled nursing home health visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found that the enrollee has a medical history including spinal stenosis, neuropathy, hyperlipidemia, hypertension, and osteoarthritis. The enrollee has received previous physical therapy, occupational therapy, skilled nursing visits, and a home health aide. In this case, the documentation doesn't support that the enrollee requires additional skilled nursing services or skilled rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition, and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems. The enrollee has received skilled rehabilitation with improved function but the documentation no longer indicates a significant improvement. The enrollee has had adequate skilled therapy to teach and establish a home exercise 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 8 physical therapy home health visits, 6 occupational therapy home health visits, and 3 skilled nursing home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 physical therapy home health visits, 6 occupational therapy home health visits, and 3 skilled nursing home health visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull to thigh (78815).

You asked the Plan to pre-approve a PET CT scan from the skull to thigh. 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. 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 pre-approve a PET CT scan from the skull to thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records submitted are incomplete. It looks like biopsy revealed carcinoma of the prostate; Gleason 4 + 5. There is a note concerning radiation therapy but no details. Axumin PET/CT has been requested but denied absent the results of a bone scan and CT. Incidentally, there are orders in the chart for bone scan and CT of the abdomen and pelvis dated April 2, 2021 but no results of those scans are submitted.

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 PET CT scan from the skull to thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull to thigh (78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 31, 2020, to September 7, 2020.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient care was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 31, 2020, to September 7, 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 revascularization (37221) provided on December 20, 2019.

You asked the Plan to pay for revascularization. You say that this code is supported. The Plan denied your request. The Plan says this is not documented in the records.

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 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 revascularization. Our reviewer says that this code is not supported. Our physician reviewer found the medical records provided does not include sufficient documentation to validate a that procedure 37221 (revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed) was performed separately from procedure 34709 (placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer)also performed and paid on December 20, 2019. Therefore, 37221 is inclusive to 34709 and is not separately payable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does not have to pay for revascularization (37221) provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed provided October 8, 2019.
You asked the Plan to pay for the total electric hospital bed. You say that the requested item was medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital bed provided October 8, 2019.