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

We decided that the Plan does not have to pay for the revascularization (37227) provided on June 20, 2019.You asked the Plan to pay for the revascularization. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted 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 37227 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed.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 revascularization. Our reviewer says that CPT code 37227 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not document that atherectomy was performed.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 revascularization have not been met.Therefore, we decided that the Plan does not have to pay for the revascularization (37227) provided on June 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) and train of four monitoring (95937) provided on November 26, 2019.You asked the Plan to pay for the needle electromyography and train of four monitoring.. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does 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 code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas.The CPT Code Manual definition of code95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.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 needle electromyography and train of four monitoring.. Our reviewer says that CPT code 95861 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include documentation of a Needle electromyography; 2 extremities with or without related paraspinal areas being performed on November 26, 2019, therefore this service cannot be verified. Our reviewer found CPT code 95937 does not meet criteria for billing or reimbursement consideration. The medical records provided indicate the Train-of -Four testing was performed. CPT 95937 is not to be used to represent Train-of-Four testing. There is no specific CPT to be used for this service, therefore 95937 cannot be verified. 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 needle electromyography and train of four monitoring. have not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) and train of four monitoring (95937) provided on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 7, 2020 through
January 9, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review has determined that the record showed that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from January 7, 2020 through January 9, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 3 power wheelchair and accessories.You asked the Plan to providea Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair and accessories.The Plan denied your request. The Plan says there is no medical necessity demonstrated for the requested Group 3 power wheelchair.The assessment shows a Group 3 power wheelchair is not medically necessary but repairs to the existing scooter are indicated. There is no repair estimate on the enrollee's current scooter. The records show that the power wheelchair is being requested for use in a SNF.Therefore, we decided that the Plan does not have to providea Group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a commode chair, extra wide and/or heavy duty, stationary
or mobile, with or without arms, any type.
You asked the Plan to provide an extra wide/heavy duty commode chair (E0168). You say that the enrollee
needs an extra wide/heavy duty commode chair. The Plan denied your request. The Plan says the enrollee does
not weigh 300 pounds or more.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are
confined to a bed or room.
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. The enrollee
does not meet the weight criteria. Therefore, we decided that the Plan does not have to provide a commode
chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional unit of gastrostomy tube replacement (CPT 49450) provided to the enrollee on February 27, 2020.You asked the Plan to pay for the additional unit. You say that this was medically necessary.The Plan denied your request. The Plan says there is no additional documentation supporting an additional procedure which was billed and remains denied.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 49450 is "Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 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 additional unit. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee underwent a single enteral tube change, but two units of CPT 49450 were billed for the date of service. The provided records do not establish the medical appropriateness nor necessity of the disputed duplicate service.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 additional unit have not been met.Therefore, we decided that the Plan does not have to pay for an additional unit of gastrostomy tube replacement (CPT 49450) provided to the enrollee on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee was notshown to need any more skilled therapy, complicated wound care, or medical care that couldn't be done by a nurse at home.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective outer surface covering system (HCPCS L5964).You asked the Plan to pre-approve the system. You say that this is medically necessary.The Plan denied your request. The Plan says there is no documentation of special needs for protection against unusually harsh environmental situations.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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record documents the anticipated use of the prosthetic in the home for single-speed ambulation and while performing routine household chores. There is no documentation of unusually harsh environmental situations where this protective system would be 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 system have not been met.Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering system (HCPCS L5964).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a back brace provided on March 4, 2020.

You asked the Plan to waive the coinsurance for a back brace. You say that your physical therapist did not discuss payment with you. The Plan denied your request. The Plan says that the coinsurance applied is correct.

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 20% coinsurance for in-network prosthetic devices and related supplies. The allowed amount of the claim is $902.78, resulting in a coinsurance obligation of $180.56 ($902.78 x 20% = $180.56).

You have been asked to pay a 20% coinsurance for a back brace. A back brace falls within the prosthetic devices and related 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 coinsurance for a back brace provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on August 27, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.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 valid 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 drug tests have not been met.Therefore, we decided that the Plan does not have to payfordrug testing provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from October 17, 2019 to December 5, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was medically necessary. The Plan denied your request. The Plan says the Plan does not recognize this code for non-participating providers.
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 code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from October 17, 2019 to December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular pathology profiling coded 81120, 81121, 81173, 81201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, and 81404 provided on February 4, 2020.You asked the Plan to pay for the Guardant360 molecular pathology profiling. 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 81120, 81121, 81173, 81201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, and 81404 are not supported in the medical record. Specifically, this service required code 81479 to be reported. In addition, the appropriate DEX Z-code identifier must be entered adjacent to the CPT code in the comment/narrative field. Code 81479 was not billed for these services. Based on this information, we decided that Medicare rules for coverage of the Guardant360 molecular pathology profiling have not been met.Therefore, we decided that the Plan does not have to pay for the Guardant360 molecular pathology profiling coded 81120, 81121, 81173, 81201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, and 81404 provided on February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the acute care hospital for a small bowel obstruction. She was treated with lysis of adhesions, iliocolonic resection with primary anastomosis, enterotomy repairs, and complicated by ilius and requiring TNP. She is currently still requiring IV antibiotics, TPN, daily physician visits, and monitoring which warrants ongoing acute care services. Leukocytosis is improving, distention and pain is gradually improving, and passing flatus and bowel movements, however, blood count is very low. It appears the enrollee's situation is not stable enough for discharge, yet not chronic enough to suggest acute care services that would take at least another 25 days to justify LTACH transfer at this time. Care appears appropriate at the current facility. The enrollee does not require services at the proposed LTACH that are not available at the current acute care hospital. There are no services available at the proposed LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, continued care at the current facility appears most appropriate. LTACH services will be considered not medically necessary 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on February 18, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you are unable to pay for this. The Plan denied
your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has
been exceeded.
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, full mouth or panoramic x-rays are
limited to one procedure every five years. The record shows that you received a complete series of intraoral xrays
on November 6, 2019 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the panoramic x-ray provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee needs a Group 3 power wheelchair with a power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses provided on January 27, 2020.You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says the eyewear benefit only covers up to the maximum allowed amount of a $150 eyewear allowance. The $150 eyewear benefit was exhausted with this purchase.Medicare generally does not cover routine eyewear services. However,the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum allowed amount of $150 for the eyewear. Therefore, we decided that the Plan does not have to pay for contact lenses provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a life alert system.You asked the Plan to pre-approve a life alert system. You say that your physician recommended you have a life alert system. The Plan denied your request. The Plan says life alert systems are not primarily medical in nature and therefore not covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. A life alert system is an emergency communications system which does not serve a diagnostic or therapeutic purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve a life alert system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services from December 3, 2019 through December 23, 2019 by a non-Medicare provider.
You asked the Plan to pay for the services. You say that the stay was medically necessary. The Plan denied your request. The Plan says you self-referred to this facility and received non-emergent care out-of-network without prior authorization, from a non-Medicare participating provider. The Plan states review of the available medical records, you were not in a non-emergent condition at time of intake into the facility.
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 services from December 3, 2019 through December 23, 2019 by a non-Medicare provider.