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

We decided that the Plan does not have to reimburse you for the home health aide services provided from February 19, 2021, to March 6, 2021. The Plan also does not have to pay for the home health aide services provided from March 7, 2021, to March 22, 2021.

You asked the Plan to reimburse you for the home health aide services provided from February 19, 2021, to March 6, 2021, and to pay for the home health aide services provided from March 7, 2021, to March 22, 2021. You say that the agency that the Plan referred you to was not able to provide aides due to the Covid-19 testing requirements. You say that you had to hire another agency that had aides available. You say that the Plan should cover 35 hours of aides per week. You also say that the Plan should reimburse the enrollee for the money she has already paid out of pocket. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for services performed by a provider that has opted out of Medicare. The Plan also says that there are in network providers available to provide these services.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you or pay for the home health aide services provided from February 19, 2021, to March 6, 2021. The Plan also does not have to pay for the home health aide services provided from March 7, 2021, to March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Canalith repositioning procedure represented by code 95992 provided on December 14, 2020.
You asked the Plan to pay for code 95992. You say that the medical records support the billing of code 95992 provided on December 14, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of code 95992 provided on December 14, 2020.
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 95992 is Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day. 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 code 95992. Our reviewer says that the medical records do not support the billing of code 95992 provided on December 14, 2020. Our physician reviewer found the records provided for review from the date of service under review did not demonstrate that a service as defined by 95992 was performed at the time of service. There was no documentation provided that the member had received such services on the date of service for which this code was submitted. As such this CPT code cannot be said to have been used appropriately. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 95992 have not been met. Therefore, we decided that the Plan does not have to pay for the Canalith repositioning procedure represented by code 95992 provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation, per site (D7953) provided on March 8, 2021.

You asked the Plan to pay for the bone replacement graft. You say that you called the dental Plan and were told this was a covered service. The Plan denied your request. The Plan says this service is not covered by your dental 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. Based on the documentation provided, it appears that the service that was initially inquired about was a bone replacement graft for a retained natural tooth (D4263). This service is listed as covered in the Plan's contract, however the service that was billed to the Plan was a bone replacement graft for ridge preservation (D7953), which is a different service and is not covered by your dental benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation, per site (D7953) provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01230 provided on January 27, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 01230 is anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified.

We find that CPT code 01230 is not supported in the medical record. Specifically, these services were billed with place of service 22 (outpatient); however, the documentation supports that the enrollee was inpatient during this date of service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01230 provided on January 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided January 5, 2021, to January 15, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you would like your copayment reduced. The Plan denied your request. The Plan says the copayment has been 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 a $390 copayment per day, days 1 to 5, for inpatient hospital care.

You have been asked to pay a total of $1,950 ($390 copayment x 5 days = $1,950) for the inpatient hospital services. This service falls within the Inpatient hospital care 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 inpatient hospital services provided January 5, 2021, to January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress (CPT code E0294).
You asked the Plan to pre-approve the DME. You say that you are not able to sleep properly and waking with serious pain are hindering your recovery to a functional level. The Plan denied your request. The Plan says there is no documentation that you have a medical condition which you would qualify for a medical hospital bed.
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 DME. Our physician reviewer found there is no documentation that you meet the requirements listed in the LCD: Hospital Beds and Accessories (L33820) for Medicare coverage of the requested hospital bed, semi-electric. The available records do not document that you have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed or requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or requires the head of the bed to be elevated more than thirty (30) degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or requires traction equipment, which can only be attached to a hospital bed. In addition, the records do not document you require frequent changes in body position and/or have an immediate need for a change in body position. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress (CPT code E0294).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on March 20, 2020, by an OON provider.

You asked the Plan to pay for the OON services. You say that the enrollee informed you they were covered under Medicare. The Plan denied your request. The Plan says it is the provider's responsibility to check eligibility prior to rendering services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on March 20, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the teletherapy isodose plan; complex (77307), the special medical radiation physics consultation (77370), and the design and construction of radiation treatment devices (77334) provided on February 25, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $60 copayment per visit for sleep studies and nuclear medicine or radiation therapy, including but not limited to cancer treatment.
You have been asked to pay a $60 copayment for the services provided. Although you did not receive radiation therapy on this day, the design and construction of radiation treatment devices provided falls under the benefit category for radiation therapy. 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 teletherapy isodose plan; complex (77307), the special medical radiation physics consultation (77370), and the design and construction of radiation treatment devices (77334) provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received February 23, 2021.
You asked the Plan to pay for the panoramic radiographic image. You say that you had severe tooth pain and needed to have your dental issue resolved. The Plan denied your request. The Plan says this service is only covered once every five calendar years.
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. The Plan covers one panoramic radiographic image every five calendar years.
We looked the file, and Medicare rules. The Plan only covers one panoramic radiographic image every five calendar years. The Plan has submitted evidence that coverage for the requested service was last provided on November 11, 2020. When you received this service on February 23, 2021, your benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on December 15, 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 97530 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were rendered in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee in this case. The enrollee is undergoing a planned total knee arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right ankle.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says this is 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 an MRI. Our reviewer says that an MRI of the right ankle is not medically reasonable and necessary in this case. Our physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows the request to have an effective diagnostic role for the noted pathology. There are well-established other testing methods to confirm the diagnosis of gout in the ankle. Furthermore, detailed documentation is not evident regarding how the MRI would change the treatment plan. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, an MRI of the right ankle is not medically reasonable or 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right ankle.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 12, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 12, 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 IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 medical records show the enrollee is medically stable. The medical records do not show the enrollee requires an intensive nursing or therapy program. IRF admission is not medically necessary based on the lack of medical complexity and high functional level. The enrollee does not require at least 3 hours a day/5days a week, or 15 hours over 7 consecutive days, of therapy services. Medicare coverage criteria are not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 an expandable controller (E2377, E2313, E2311), push handles (K0108), and bag hooks (K0108).
You asked the Plan to pre-approve an expandable controller, push handles, and bag hooks. You say that these items are medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options with their own switches and the other items are not medical.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is medically necessary for any of the functions listed in the LCD. Medicare will not pay for equipment that is primarily and customarily used for nonmedical purposes. 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 an expandable controller, push handles, and bag hooks. Our reviewer says that the requirements for coverage of the requested items have not been met. Our physician reviewer found the patient's strength and function in the upper extremities with the ability to feed himself indicates that the patient can control any power options through their own individual switches, meaning the expandable controller is not medically necessary. The push handles and bag hooks are not medical in nature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, push handles, and bag hooks have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), push handles (K0108), and bag hooks (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.

You asked the Plan to pre-approve a panniculectomy. You say that the requested panniculectomy is medically necessary. The Plan denied your request. The Plan says the requested panniculectomy is not medically necessary.

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 panniculectomy. Our reviewer says that the requested panniculectomy is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a pannus with induration. There is no documentation of intertrigo or failure of treatment. The record does not indicate the stage of the pannus nor are there pictures provided. The record provided does not support the medical necessity or reasonableness of the requested service. The elements of the coverage criteria are not satisfied. 

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 panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy.