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

We decided that the Plan does not have to pay for the neuromuscular electrical stimulation (NMES) device coded as E0745 and the knee braces and suspension sleeves coded with both RT and LT modifiers.

You asked the Plan to pay for the NMES device and knee braces with suspension sleeves. You say that this is medically necessary. The Plan denied your request. The Plan says the knee braces are not coded correctly, and the TENS unit is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that NMES is only covered for treatment of disuse atrophy caused by certain conditions. The rules also say that it is incorrect coding to bill bilateral knee braces as two units on one line item with both RT and LT modifiers.

Review of the claim shows that the knee braces and related sleeves were coded incorrectly on the same line item. Regarding the NMES, the limited documentation does not clearly show that this was requested for a covered indication. There is no documentation of muscle atrophy nor description of the cause. Therefore, we decided that the Plan does not have to pay for the neuromuscular electrical stimulation (NMES) device coded as E0745 and the knee braces and suspension sleeves coded with both RT and LT modifiers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that in order for the medical services to be covered under your Plan they must be received from providers contracted with the Plan. The only exceptions to this are in cases of urgent or emergently-needed care, if the medical care required cannot be provided by contracted, in-network providers and the Plan has given prior authorization for such care or kidney dialysis services obtained at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.

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 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 physician's services to be provided by the out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on June 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim has been recoded as CPT 99284, which is more appropriate.
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity." 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 records for the emergency room visit do not support CPT 99285. The documentation supports a detailed history (extended HPI, and ROS 9), a comprehensive examination (8 + organ systems), and medical decision making of moderate complexity (prescription drug therapy), therefore, CPT 99284 would be the appropriate code to report. 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 emergency department services (CPT 99285) provided to the enrollee on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110).

You asked the Plan to pay for the dental service. You say that as people get older, dental coverage should be increased. You also say that you cannot afford to pay for this service out of pocket. The Plan denied your request. The Plan says prophylaxis is covered twice per plan year. The Plan also says that the frequency limit for this service 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, the frequency limit of 2 prophylaxes per plan year has been exceeded. The record shows that the Plan paid for this service. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extensive arthroscopic debridement (29823) provided on June 25, 2020.
You asked the Plan to pay for extensive arthroscopic debridement. You say that this service was requested by the surgeon. The Plan denied your request. The Plan says this code 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 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 extensive arthroscopic debridement. Our reviewer says that this code is not supported. Our physician reviewer found the operative report documents a Labrium debridement, indicating that the debridement was limited. To report extensive debridement, the record should document the debridement of multiple soft tissue structures (labrum, subscapularis, supraspinatus) or a chondroplasty of the humeral head or glenoid. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extensive arthroscopic debridement have not been met. Therefore, we decided that the Plan does not have to pay for extensive arthroscopic debridement (29823) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 14, 2020 to September 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visits (99213). You say that you would like reconsideration because you received a referral to this provider from your primary care physician. The Plan denied your request. The Plan says this provider is out-of-network and there is no referral on file from your primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 14, 2020 to September 28, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen services coded R0070 provided on January 6, 2020.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. 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. In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. We find that CPT code R0070 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) Indicator of 3. The rules for payment of this service are not met. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen services coded R0070 provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services provided from July 9, 2020, to September 14, 2020.
You asked the Plan to reimburse you for the dental services. You say that the dental services should be covered under Medicare as you have been experiencing chronic infection, severe bone loss, extraction and bone graft to regenerate lost bone, and the on-going follow up appointments still in effect. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan says the services are not covered by Medicare. The Plan says there is an allowance of $100 per year for dental services. The Plan also says that the allowance has been exhausted.
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 $100 allowance has been exhausted. The record shows that the Plan paid $100 towards the cone beam CT capture and interpretation that you received on July 9, 2020. Additionally, the Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to reimburse you for the dental services provided from July 9, 2020, to September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 1, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 1, 2020 by a non-participating provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided by an out of network (OON) provider.

You asked the Plan to pay for OON mental health care. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the mental health services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided
on August 22, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor supplies. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing
required information.
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 does not contain a valid proof of delivery or relevant medical records which support medical
necessity for the supplies provided in this case. A signed proof of delivery was not provided with the
documentation. In addition, the prescribing physician informed the Plan that they did not refer the enrollee to
this rendering company for the items rendered. The record shows that the Plan made several attempts to obtain
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the
therapeutic continuous glucose monitor supplies provided on August 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).

You asked the Plan to preapprove the CGM. You say that you travel a lot and it is difficult to find test strips. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for grafting services (CPT 15771) provided to the enrollee on January 14, 2020.
You asked the Plan to pay for the services. You say that you would like reconsideration based on records submitted. The Plan denied your request. The Plan says the documentation does not support the service billed
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 15771 is "Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate." 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 submitted. Our coding reviewer found the medical records submitted do not include sufficient documentation to meet the guidelines of a Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate, therefore this procedure cannot be verified for January 14, 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 grafting services (CPT 15771) provided to the enrollee on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 2, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you are asking that the copayment be waived because you received a COVID diagnosis while inpatient. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received ambulance services on September 2, 2020. You were asked to pay a $325 copayment for the ambulance services. Your 2020 EOC states that enrollees must pay a $325 copayment per one-way trip for Medicare-covered ambulance services. 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 ambulance services provided on September 2, 2020.
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 it is not clear why the enrollee cannot start therapy in a less intense 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 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 is living at home. She receives outpatient wound care for a sacral ulcer. She has home health services and has weakness and declining function. 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 the 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: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing.

You asked the Plan to pay for lab test. You say that your provider does not physically see the enrollee, only receives a sample sent to the lab. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-network with the Plan.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician for this testing was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would be non-covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing.

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.