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

 
We decided that the Plan does not have to pay for the laboratory services coded 80201, 80162, 80159, 80173, 
80157, and 80177 provided on March 10, 2020. 
 
You asked the Plan to pay for the laboratory 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. 
 
We find that CPT codes 80201, 80162, 80159, 80173, 80157, and 80177 are not supported in the medical 
record. Specifically, the documentation submitted did not support that these services were performed with 
blood sampling. Blood specimen collection is by venipuncture, however, the specimen collected for the billed 
code is not documented; therefore, the billed services are not supported by the documentation. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80201, 80162, 
80159, 80173, 80157, and 80177 provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (any type) with a non-invasive 
interface for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no recent clinical documentation provided to support the ongoing need for 
this device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has a diagnosis of COPD, and is on supplemental oxygen, but there are no pulmonary function tests to confirm 
the diagnosis of COPD. The enrollee is morbidly obese, and obesity-hypoventilation could be playing a role. 
However, there is no documentation of CO2 retention on ABG while in a stable state. In addition, Medicare 
does not cover a home ventilator when used as BiPAP. A home ventilator is 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (any type) with a non-invasive interface for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic inserts and related strapping procedures 
provided on March 4, 2019. 
 
You asked the Plan to pay for the shoe inserts and strapping. You say that these are shown to be medically 
necessary and should be covered. The Plan denied your request. The Plan says there is no valid order or proof 
of delivery in the records. 
 
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 physician order or proof of delivery for the supplies provided in this case. 
There is no written order signed by the physician for these items, nor is there an invoice signed by the enrollee 
or authorized third party indicating that these items were provided. The note of the visit also does not indicate 
that any services described by 29799, casting/strapping procedures were performed. 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 orthopedic inserts and related strapping procedures provided on March 4, 
2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT Code 74177). 
 
You asked the Plan to pre-approve the CT scan. You say that the imaging is necessary. The Plan denied your 
request. The Plan says that the imaging is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our physician reviewer 
found repeat CT abdomen/pelvis was requested as the radiologist who read the prior CT suggested short-term 
repeat CT to rule out carcinomatosis. Although follow-up imaging for resolving abdominal symptoms is not 
generally warranted, follow-up on suspicious findings suggestive of possible carcinomatosis is justified when 
the diverticulitis has resolved, which appears to be the case here. Therefore, this request for repeat CT 
abdomen/pelvis will be considered 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, abdomen and pelvis; with contrast material(s) (CPT Code 74177).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80157: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
 
 
CPT 80201: 
 
Topiramate 
 
 
We find that the denied codes are not supported in the medical record. Specifically, the services were done by 
urine sampling rather than blood sampling. 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 drug 
testing services provided to the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pay fora full thickness graft (CPT 15260) provided to the enrollee on November 24, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysthatCurrent Procedural Terminology (CPT) code 15260-59 (1 unit) remains 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 15260 is "full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less."We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pay for the services. Our reviewers saythat the services at issue in this case were supported by the medical records. Our physician reviewer found the piece that had been avulsed was then prepared and used as a full thickness skin graft to the injured site. This is clearly documented in the operative note dated 11/24/2019.  The procedure is consistent with the use of a full thickness graft -CPT code 15260. The full thickness graft did not have to be obtained from a separate incision so there is no donor site defect. However, this does not mean that the procedure performed is not consistent with CPT 15260.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 been met.Therefore, we decided that the Planhas to pay fora full thickness graft (CPT 15260) provided to the enrollee on November 24, 2019.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT Code 64625).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the requested cooled Radiofrequency Ablation is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency.
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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT Code 64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two osseous surgeries of four or more contiguous teeth or tooth bounded spaces (D4260 x2), two osseous surgeries of one to three contiguous teeth or tooth bounded spaces (D4261 x2), two bone replacement grafts (D4263 x2), and guided tissue regeneration (D4266). You asked the Plan to pre-approve the osseous surgeries, bone replacement grafts, and guided tissue regeneration. You say that your previous bridge did not fit well. You also say that you would like these services in order to prevent tooth loss, and to support your bridge better. The Plan denied your request. The Plan says these services are not covered under your benefit package. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two osseous surgeries of four or more contiguous teeth or tooth bounded spaces (D4260 x2), two osseous surgeries of one to three contiguous teeth or tooth bounded spaces (D4261 x2), two bone replacement grafts (D4263 x2), and guided tissue regeneration (D4266).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 24, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that the services were provided due to COVID-19 but you are told that copayments are not waived until March 25, 2020. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $265 copayment for ambulance services. 

You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and collection of venous blood by 
venipuncture services provided on January 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and collection of venous blood by venipuncture services. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
rendered are not a covered benefit. 
 
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 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 office visit and collection of venous blood by 
venipuncture services provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (CPT Codes 37243, 37242, 
36248 and 36247) to be performed by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this procedure is considered experimental and unproven for treatment of lower urinary 
tract symptoms. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the items/services at issue in this case are not medically reasonable and necessary. This 
procedure is considered experimental and unproven for treatment of lower urinary tract symptoms. According 
to the most recent AUA Guidelines: "PAE is not recommended for the treatment of LUTS attributed to BPH 
outside the context of a clinical trial." 
 
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 prostate artery embolization (CPT Codes 37243, 37242, 36248 and 36247) to be 
performed by an out-of-network provider.
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 the enrollee has had a change in clinical 
states and moved back to the ICU. You say that you would greatly benefit from an LTACH stay. You say that 
there is not a SNF in the area that will accept you with your current clinical status. The Plan denied your 
request. The Plan says the records do not show that the enrollee needs further inpatient level of care. The Plan 
says that the documentation does not show that there is a need for specialized skilled nursing, nor have there 
been failed attempts for the enrollee to breathe on their own. 
 
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 the enrollee's ongoing care needs include respiratory support with ventilator 
management and tracheostomy care, nebulizer treatments, intravenous antibiotics, surveillance laboratory 
studies, close fluid balance, and therapy services. The documentation does not support that the enrollee in this 
case requires services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the clinical information provided supports the need 
for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. The Plan says that the enrollee could receive the care needed in another 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 above. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of 
rehabilitative services with regular physician evaluation. 
 
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.
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 the enrollee is clinically stable to be 
transferred to an LTACH level of care. You say that the enrollee's doctors will round on a daily basis and he 
will get physical therapy to help him to maintain/regain his strength. The Plan denied your request. The Plan 
says the enrollee can receive the care required at the current hospital. 
 
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 the enrollee's ongoing care needs include oxygen supplementation, intermittent 
CPAP, nebulizer treatments, surveillance laboratory studies, scheduled hemodialysis, wound care, and therapy 
services. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. There are no required medical 
services identified that are available at the LTACH, that are not available at the current 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 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 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.