Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapy services coded 97110, 97112, 97140 and G0283 provided on July 15, 2020.You asked the Plan to pay forthe therapy 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 97110, 97112, 97140 and G0283 are not supportedin the medical record. Specifically, the medical records submitted do not support at least 8 minutes of therapy which is the minimum requirement needed in order to bill therapy services. Therefore, codes 97110 and 97112 cannot be verified. The medical records submitted indicate a plan to perform electrical stimulation (unattended), to one or more areas for indication(s) other than wound care. However, the records didn't include the area(s) of the body to which the electrical stimulation was applied; therefore, code G0283 cannot be verified. Code 97140 was billed with modifier 59. The medical records submitted do not indicate the amount of time spent performing this service separate and distinct from other services performed on the same date of service. Therefore, the billed code and modifiers cannot be verified. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay forthe therapy services coded 97110, 97112, 97140 and G0283 provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and core at tooth # 7 (D2954).

You asked the Plan to pre-approve dental code D2954. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services are not covered.

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 prefabricated post and core at tooth # 7 (D2954)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services tobe provided by the out-of-network provider.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorizationfrom the plan.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided bythe out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea semi-electric hospital bed.You asked the Plan to pre-approvethe semi-electric hospital bed. You say that you had this bed in rehab and need to have it in the home as well.The Plan denied your request. The Plan says that the criteria for a semi-electric hospital bed have not been met in this case.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requiresfrequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that the documentation supports the medical necessity of the requested bed. Our physician reviewer found with hemiparesis, the enrollee is at risk for pressure-related injury and will often need assistance or have difficulty positioning in bed. This semi-electric bed is indicated and medically reasonable for the enrollee's needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the semi-electric hospital bed have been met.Therefore, we decided that the Plan has to pre-approvea semi-electric hospital bed.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 aletter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition infusion pump, portable (B9004) provided.

You asked the Plan to pay for the infusion pump. You say that the claim has not been paid in full or under the terms of the contract for the services provided.The Plan denied your request. The Plan says the records do not support the service billed 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, proof of delivery and an itemized shipping/billing invoice for the supplies provided in this case. 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 parenteral nutrition infusion pump, portable (B9004) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter (E1230).You asked the Plan to pre-approvethe power scooter. You say that the powered mobility device is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that if any Powered Mobility Device is only for use outside the home, it will be denied as non-covered. We looked at the file and Medicare rules. The record shows the enrollee can move about their home without any mobility aid. The record also shows the power scooter is intended for use outside the home. Based on this information, we decided that Medicare rules for coverage of the power scooter have not been met.Therefore, we decided that the Plan doesnot have to pre-approvea power scooter (E1230).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiography to be provided by an out of network provider.You asked the Plan to pre-approvea transthoracic echocardiography (93303). You say that the transthoracic echocardiography is medically necessary.The Plan denied your request. The Plan says they have in-network providers who can provide this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan hasto pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvea transthoracic echocardiography to be provided by an out of network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted procedure, femur or knee with CPT code 27599 provided.

You asked the Plan to pay fo rCPT code 27599. You say that the medical records support the billing of CPT code 27599.

The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 27599.

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 27599 is Unlisted procedure, femur or knee.

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 CPT code 27599. Our reviewer says that the medical records do not support the billing of CPT code 27599. Our physician reviewer found the enrollee has debridement surgery for an infected femur. The operation report does not clearly describe or document an unlisted procedure. The code is not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27599 have not been met.Therefore, we decided that the Plan does not have to pay for unlisted procedure, femur or knee with CPT code 27599 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.You asked the Plan to pre-approve the physician'sservices. The Plan denied your request. The Plan says the Plan does not cover non-emergency services by a non-contracted provider when a contracted provider can provide the services. The Plan has many contracted providers that can provide the services you need.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 availablewho can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvephysician's services to be provided by the out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 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 be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forintermittent limb compression device for services provided February 28, 2020.You asked the Plan to pay forintermittent limb compression device. You say that you had umbilical hernia surgery on this day and was not aware of getting any compression device or anything that required authorization.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for DVT prophylaxis.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to pay forintermittent limb compression device for services provided February 28, 2020
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe dental services provided on August 12, 2020.You asked the Plan to pay forthe dental services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the provider has opted out of Medicare.The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.We confirmed that the provider is not listed on Medicare's Opt Out Affidavits dataset. There is no evidence that the enrollee has signed a private contract with the provider for the services at issue. The Plan has provided no documentation in the case file as proof the provider hasopted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the dental services have been met.Therefore, we decided that the Plan has to pay forthe dental services provided on August 12, 2020.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 to review. The Plan has to show us the mistake and/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective cover (L5962).
You asked the Plan to pre-approve a protective cover (L5962). You say that the requested protective cover
(L5962) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria
for the requested protective cover (L5962).
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 protective cover (L5962). Our
reviewer says that the enrollee does not meet criteria for the requested protective cover (L5962). Our physician
reviewer found the enrollee is with a left below knee amputation. The enrollee has phantom limb syndrome
with pain. The documentation does not support that the enrollee has special needs for protection against
unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the
level of protection that is afforded by L5704, L5705, L5706, and L5707.
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 protective cover (L5962) have not been met. Therefore, we decided that the
Plan does not have to pre-approve a protective cover (L5962).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medicallynecessary.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 relevantMedicare 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 required minimal assistance for rolling and sitting up. The enrollee required supervision/moderate assistance for upper body and lower body bathing. The documentation supports that the enrollee's pain was well controlled. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, abdomen (74018) provided July 27, 2020.
You asked the Plan to waive the copayment for the radiology services. You say that you are appealing removal of the $50 because at no time were you advised the disc you picked up was not compatible for reading. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $50 copay for services in an outpatient hospital facility.
You have been asked to pay $50 copay for the radiology services. The radiology services fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 radiologic examination, abdomen (74018) provided July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegastric bypass surgery.You asked the Plan to pre-approvethe gastric bypass surgery. You say that the bariatric surgery 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 your Body Mass Index must be at 35 or more to qualify for weight loss surgery. We looked at the file and Medicare rules. The provided information shows that your Body Mass Index is less than 35. No medical records were provided to show that other treatment measures failed. Based on this information, we decided that Medicare rules for coverage of the gastric bypass surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvegastric bypass surgery.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe lower abdominal panniculectomy. We decided that the Plan does not have to pre-approvepanniculectomy of the upper abdominal pannus. You asked the Plan to pre-approvethe panniculectomy. You say that you would like reconsideration because you have excess skin which causes you pain.The Plan says that you do not meet Medicare coverage criteria.We decided that the Planhas to pre-approvethe lower abdominal panniculectomy. The Plan follows Medicare rules. Medicare rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, 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 pre-approve the panniculectomy. Our reviewer says that you are noted to have clear evidence of functional impairment due to the excess soft tissue of the lower abdomen.  Skin breakdown would not likely resolve with dermatologic management (non-surgical management.)
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 Panniculectomy have been met.Therefore, we decided that the Plan has to pre-approvethe lower abdominal panniculectomy. We also decided that the Plandoes not have to pre-approvepanniculectomy of the upper abdominal pannus.The Plan follows Medicare rules. Medicare rules saythat medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury.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 panniculectomy of the upper abdominal pannus. Our physician reviewer found the functional impairment is specifically documented to be related to the lower abdominal pannus and not the upper abdominal pannus.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of panniculectomy of the upper abdominal pannus have not been met.Therefore, we decided that the Plan does not have to pre-approvepanniculectomy of the upper abdominal pannus.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 toopen the case again, we will send you a letter.