Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the procedure codes 20610 and 64612 provided on March 3, 2021.

You asked the Plan to pay for the procedure codes 20610 and 64612. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the medical records do not support the services as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 20610 is Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance and 64612 is Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm).

We asked our coder 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 procedure codes 20610 and 64612. Our reviewer says that the requested services are not supported by the submitted medical documentation. Our reviewer found in this case, the documentation supports steroid injection as being performed. Therefore, CPT 64612 would not be covered. For CPT 20610 procedure report documents "Verbal consent was obtained for arthrocentesis of the left and right Sacroliliac joints". There is a more appropriate code to report for sacroiliac joint arthrocentesis. 

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 procedure codes 20610 and 64612 have not been met. Therefore, we decided that the Plan does not have to pay for the procedure codes 20610 and 64612 provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is not medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary drainage bag (A4358), indwelling catheter; foley type (A4346), and the extension drainage tubing (A4331) rendered by the OON provider on April 27, 2021.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the urinary drainage bag (A4358), indwelling catheter; foley type (A4346), and the extension drainage tubing (A4331) rendered by the OON provider on April 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 12, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you had to go to the ER because your feeding tube had a defective part. 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 $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on March 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you received on October 9, 2019, at an outpatient hospital facility.
You asked the Plan to waive the copayment for the TTE. You say that you should not have to pay this because the claim is so old. You also stated that you did not have these services. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were seen on this date of service as part of a cardiology consultation and the records confirm that you received the TTE at issue.
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 $200 copayment for diagnostic tests and procedures at an outpatient hospital facility. You have been asked to pay a $200 copayment for the TTE. The TTE falls within the diagnostic tests and
procedures at an outpatient hospital facility 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 transthoracic echocardiography (TTE) you received on October 9, 2019, at an outpatient hospital facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left atrial appendage closure.

You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that left atrial appendage closure is covered for the indications established in the applicable NCD. 

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 procedure. Our reviewer says that left atrial appendage closure is not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of a formal shared decision-making process involving the use of an evidence-based decision tool showing the enrollee at high risk for bleeding on long-term anti-coagulation therapy. The stated reason for the need for the occluder device in lieu of anticoagulation is that the enrollee camps, hikes and fishes in the woods and could possibly sustain an injury there. This would not be considered an evidence-based increased risk for bleeding on chronic anti-coagulation based on the CMS NCD (20.34) guidelines. These NCD criteria permit the use of the Watchman occluder device as second line therapy only when there is a failure of oral anticoagulation, a prior bleeding complication or an elevated bleeding risk based on evidence-based risk criteria such as an elevated HAS-BLED score. The enrollee would therefore not meet the applicable CMS NCD 20.34 criteria for Watchman device implantation at this time. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve left atrial appendage closure.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on March 4, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests/panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular-respiratory disease.

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 follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on March 4, 2021.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the endoscopy procedure you had at an ambulatory surgery center on February 26, 2020.
You asked the Plan to reduce the copayment for the endoscopy procedure. You say that you believe your copayment should only be $45 because that was the cost in previous years. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the endoscopy center where you had this procedure is considered an ambulatory surgery center.
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 $200 copayment for services in an ambulatory surgical center. You have been asked to pay a $200 copayment for the endoscopy procedure. The endoscopy procedure falls
within the services in an ambulatory surgical center 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 reduce the copayment for the endoscopy procedure you had at an ambulatory surgery center on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021.

You asked the Plan to pay for lab tests. You say that these tests were needed for the enrollee's care. The Plan
denied your request. The Plan says the denial of payment for these tests is correct, because these tests are not
covered by Medicare for the diagnosis listed and were performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The documentation does not show that the results of this testing were requested by the enrollee's treating
physician to diagnose or treat a specific medical condition. This is considered screening. Medicare does not
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for
laboratory testing provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 13, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the Plan cannot determine how the enrollee came to this servicing provider or whether the services were medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance, for a therapeutic continuous glucose monitor, provided on March 26, 2021.
You asked the Plan to pay for the supply allowance for a therapeutic continuous glucose monitor (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition, nor did it indicate the provider discussed the need, for the billed supply code.
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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The medical record of the office visit on April 12, 2021 does not show that the enrollee uses a CGM or that the physician discussed a CGM. Based on this information, we decided that Medicare rules for coverage of the supply allowance for therapeutic continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance, for a therapeutic continuous glucose monitor, provided on March 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 17, 2021, through March 18, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says there are no daily skilled nurse or therapist needs.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, could be provided at a lower level of care (ex. intermittent therapy, restorative therapy, long term 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from February 17, 2021, through March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rural health clinic visit provided on January 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rural health clinic visit. You say that no authorization is required to support the current procedural terminology (CPT) code. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 rural health clinic visit provided on January 19, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is necessary for you. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.

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 that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on November 5,
2019 to November 11, 2019.

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 are not covered.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.

We looked at the file and Medicare rules. Billed procedure code G0129 (occupational therapy services
requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization
treatment program, per session [45 minutes or more]) has a status indicator of X and is statutorily excluded
from Medicare payment. Therefore, we decided that the Plan does not have to pay for the occupational therapy
services rendered on November 5, 2019 to November 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 4, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this was medically necessary. 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. In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of any therapeutic services being performed. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional
intraoral periapical x-ray (D0230) provided on April 27, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. You say that you believe these services should be
covered. The Plan denied your request. The Plan says the $16.66 copayment applies because according to your
EOC you pay a 50% coinsurance for Class 2 Basic Services.

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, you are responsible for a 50%
coinsurance for Class 2 Basic Services including single tooth x-rays. Therefore, we decided that the Plan does
not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230)
provided on April 27, 2021.