Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on September 21, 2020 by an outof-
network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that these services were provided in good faith. You
would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization
was not obtained by the member's 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 psychotherapy provided on September 21, 2020
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97530) provided on June 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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 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 use of code 97530 is not supported by the records provided. Our coding reviewer found that a certified occupational therapy assistant (COTA) performed these services in the enrollee's home, therefore, HCPCS code G0158 is a more appropriate code to report for this service.

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 the services (97530) provided on June 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on January 13, 2021.
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, codes S1015 and S8301 have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided
on April 20, 2021.

You asked the Plan to pay for the subsequent hospital care 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 separately
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 99233 is subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed
interval history; A detailed examination; Medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient is unstable or has developed a significant complication or a significant new problem.
Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

We find that CPT code 99233 is not supported in the medical record. Specifically, this service is considered
being part of the global surgical package for minor procedure of code 43244 (Esophagogastroduodenoscopy,
flexible, transoral; with band ligation of esophageal/gastric varices), which was billed on the same date of
service by the same provider. Based on this information, we decided that Medicare rules for coverage of the
subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay
for the subsequent hospital care services coded 99233 provided on April 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February 8, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you should not be responsible for the copayment because you requested the beneficiary be removed from the ambulance, as you had an alternative private ambulance service, but the provider denied. The Plan denied your request. The Plan says the cost share was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ambulance trip for ambulance services.

The enrollee has been asked to pay a $250 copayment for each one-way Medicare-covered ambulance trip for ambulance services. This service falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuroplasty (64708) provided on December 16, 2020.

You asked the Plan to pay for the neuroplasty. You say that you would like reconsideration based on the 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 64708x2 is neuroplasty, major peripheral nerve, arm or leg, open; other than specified. 

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 neuroplasty. Our reviewer says that CPT code 64708 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not clearly document a surgical decompression of freeing of intact nerve from scar tissue, including external neurolysis and/or transposition to repair or restore the nerve. Documentation supports radial nerve dissection. 

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 neuroplasty have not been met. Therefore, we decided that the Plan does not have to pay for the neuroplasty (64708) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).

You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options through their own switches.

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. 

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. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the patient's strength and function in the upper extremities with the ability to feed herself supports that the patient can control any power options through their own individual switches. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be
provided in a different level of care. There is not a reasonable expectation that this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 3, 2021 to March 4, 2021.

You asked the Plan to pay for the orthoses. You say that the enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address COVID-19 concerns. The Plan denied your request. The Plan says this supplier is not enrolled and/or certified with Medicare. There is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 3, 2021 to March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic items provided from March 10, 2021 to March 11, 2021.

You asked the Plan to pay for orthotic items. You say that the beneficiary requested services utilizing access to
telemedicine from the physician of their choice. The Plan denied your request. The Plan says the denial of
payment for these items is correct, because the packing slip submitted did not include the carrier's tracking
number nor did the proof of delivery include details to corroborate the specific items billed.

The Plan must follow Medicare rules. Medicare rules say that Medicare plans may require proof of delivery to
verify that the beneficiary received billed DMEPOS items.

We looked at the file and Medicare rules. The documentation submitted does not include valid proof of
delivery for the specific items billed on this claim.

Based on this information, we decided that Medicare rules for coverage of orthotic items have not been met.
Therefore, we decided that the Plan does not have to pay for orthotic items provided from March 10, 2021, to
March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 5, 2021, by an OON provider.
You asked the Plan to pay for the office visit. 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 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 office visit provided on February 5, 2021, by an OON 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 it is felt that the enrollee would benefit from LTACH care. The Plan denied your request. The Plan says the current facility is able to meet the enrollee's needs.
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 was admitted with pneumonia. The enrollee is improving. The enrollee continues to receive necessary acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available only at the LTACH facility. The elements of the coverage rules 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 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 pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator.

You asked the Plan to pre-approve a neurostimulator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as therapies for the relief of chronic intractable pain under specific circumstances.

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 neurostimulator. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no imaging of the enrollee's discs or spinal canal, there is no documentation of prior medication trials, multi-disciplinary consults or other interventional approaches. The request 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 a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833, L2397) provided on October 2, 2020.

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because the knee orthoses are medically necessary. The Plan denied your request. The Plan says the billed supplies are not medically necessary for the member's condition.

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 pay for the knee orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of a detailed properly performed neuromuscular examination or gait evaluation. There is no evidence of true instability. The "objective of assessment" does not indicate a knee laterality of the pivot shift or laxity pivot test and there is no indication that there is pathological laxity with objective measurements of any laxity. There is no evidence of a recent surgery or injury to the knee. There is no evidence of a gait evaluation or indication the patient is current ambulatory and requires the requested knee braces. 

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 knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833, L2397) provided on October 2, 2020.