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

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. You say that the preferred drugs are not on the formulary at their facility, and they currently do not have access to those two drugs. You say that Botox is medically necessary so that there is not a delay in care. The Plan denied your request. The Plan says there is no record from the prescriber that shows the enrollee has tried the preferred drugs and that they have not worked. The Plan says that there is no evidence that the enrollee has medical reasons that prevent using one of these preferred drugs.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Botox. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of the drugs Dysport or Xeomin before they will approve Botox. The enrollee has not tried either of these preferred drugs, according to the records provided. There is not a body of literature available that permits conclusions that the preferred botulinum toxin agents would be less effective for the enrollee. All 3 of the drugs have a level A rating for use in the enrollee's conditions. Likewise, all of the drugs have a nearly identical side effect profile. In as much, it cannot be concluded that the preferred drugs would likely be less effective or would have more adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 7, 2020, billed
with code 99100.
You asked the Plan to pay for the services as billed. You say that this code is only not payable with certain
codes that were not billed on this claim. 99100 should be reimbursed. The Plan denied your request. The Plan
says this code was denied as it is bundled in payment for the anesthesia code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule meaning that payment is bundled with payment made for other services. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on December 7, 2020, billed with code 99100.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for teeth #3 and 30.
You asked the Plan to pre-approve core buildups. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 a core buildup, including any pins when required (D2950) for teeth #3 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for alginate dressing (A6196) provided March 15, 2021.
You asked the Plan to pay for the wound care supplies. You say that these items have been paid by Medicare in
the past. The Plan denied your request. The Plan says the claim was 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 A6196 is Alginate or other fiber gelling dressing, wound
cover, sterile, pad size 16 sq. in. or less, each dressing.
We find that CPT code A6196 is not supported in the medical record. Specifically, the place of service (POS) code 31 should be used for services for patients in a Part A covered stay and place of service (POS) code 32 should be used with services for beneficiaries in a noncovered stay. The claim was billed with POS code 31. Review of the enrollee's claim history show no Part A inpatient SNF claim for the billed date of service. Therefore, the provider needs to submit a corrected claim. Based on this information, we decided that Medicare rules for coverage of the wound services have not been met. Therefore, we decided that the Plan does not have to pay for alginate dressing (A6196) provided March 15, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve EYLEA injection (aflibercept) 1 mg (J0178).
You asked the Plan to pre-approve the injection. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the Plan's Step therapy criteria for the requested drug. The enrollee has not tried and failed the preferred step therapy drug. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain documentation of trial of Bevacizumab. The documentation does not support that Bevacizumab would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve EYLEA injection (aflibercept) 1 mg (J0178).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the four exercise training payments made from June 29, 2020, through December 8, 2020.
You asked the Plan to provide reimbursement for the exercise training payments. You say that you feel that you should be reimbursed. The Plan denied your request. The Plan says it was decided that payment could be made ($60) toward the four payments made in 2021. However, the payments made in 2020 cannot be reimbursed as you were already reimbursed the full $150 benefit in June 2020.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses up to $150 per calendar year for gym services. We reviewed the file and the Plan's contractual rules. We find that the Plan has satisfied its obligations by making payment of $60 toward the services paid in 2021. The services paid in 2020 were correctly denied as that year's maximum $150 was already reimbursed to you. While you may receive reimbursement for additional services provided in 2021, no further reimbursement can be made for the payments included in this case. Therefore, we decided that the Plan does not have to provide reimbursement for the four exercise training payments made from June 29, 2020, through December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on October 7, 2020, billed with code 28043.
You asked the Plan to pay for the surgical services as billed. You say that this should be paid. The Plan denied your request. The Plan says this code is not documented in the record.
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 28043 is Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm. 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 surgical services as billed. Our reviewer says that the services described by this code are not supported. Our reviewer found the documentation states that the mass was just inferior to the incision site and measured approximately 5 by 5 cm. There is more specific code to report for this service. CPT code should be reported for tumor less than 1.5 cm, and the documentation supports more than 1.5 cm. 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 surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on October 7, 2020, billed with code 28043.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the specialist office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the specialist office visit. You say that there are no in-network providers that are available, and you need to see the specialist as soon as possible. The Plan denied your request. The Plan says the provider is out-of-network
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure(s), group (2 or more individuals) (CPT code 97150-GP), multivitamin injections (CPT code J3490 x2), and application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (CPT Code 97032) provided to the enrollee on February 2, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. TENS device including supplies is not a Medicare covered benefit with the available information. Pneumatic compression vasopneumatic devices can be covered in the home or other outpatient setting only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. Vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service. Therefore, we decided that the Plan does not have to pay for therapeutic procedure(s), group (2 or more individuals) (CPT code 97150-GP), multivitamin injections (CPT code J3490 x2), and application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (CPT Code 97032) provided to the enrollee on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous passive motion (CPM) exercise device for use other than knee (E0936).
You asked the Plan to pre-approve the CPM device. You say that you need this device to help you recover after having shoulder surgery. The Plan denied your request. The Plan says continuous passive motion devices are not covered by Medicare for the shoulder.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve continuous passive motion (CPM) exercise device for use other than knee (E0936).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after an elective revision total knee arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that your doctor requires you to be inpatient after the surgery. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your condition; your care could be provided without an inpatient stay after your surgical procedure. You don't meet any of the requirements for an inpatient stay.
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 pre-approve acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient services are met in this case. Our physician reviewer found that you are undergoing an elective total knee arthroplasty. You are medically stable, and you have been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation that you will require a greater than 2 midnight stay. The record does not show that the admitting physician would reasonably expect that your necessary hospital care after surgery 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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after an elective revision total knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).
You asked the Plan to pre-approve the hospital bed. You say that you feel you should not have been denied the bariatric bed mattress. The mattress was recommended by your doctor and the current mattress is ripped. This will support you to sleep elevated so you can breathe. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested hospital bed as he weighs under 350 pounds.
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds We looked at the file and Medicare rules. The records show that the enrollee weighs 264 pounds. The enrollee is under the 350 pounds weight criteria. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided from August 17, 2020, through August 19, 2020, and the discharge management services (99239) provided on August 20, 2020.
You asked the Plan to pay for the inpatient physician services. You say that these services should be paid. The Plan denied your request. The Plan says payment was made for the August 16, 2020 date of service; however, time spent was not documented on remaining dates as required. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also specifically state that any critical care codes must have time spent documented to be paid. The critical care progress notes submitted do not document time spent for the dates of service at issue. In addition, the code definition of 99239 is hospital discharge day management, more than 30 minutes. To support this code, notation of at least 31 minutes is required. There is no documentation of time spent on the discharge day to support use of this code. Based on this information, we decided that Medicare rules for coverage of the inpatient physician services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided from August 17, 2020, through August 19, 2020, and the discharge management services (99239) provided on August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound debridement procedure you had at an ambulatory surgery center on March 5, 2021.
You asked the Plan to waive the copayment for the wound debridement procedure. You say that you assumed there would be little to no charge for this service since it was just to have your surgery incision checked. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for surgery and other services at an ambulatory surgery center. You have been asked to pay a $125 copayment for the wound debridement procedure. The wound debridement procedure falls within the surgery and other services at an ambulatory surgery center benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the wound debridement procedure you had at an ambulatory surgery center on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression (D6793) and provisional pontic - further treatment or completion of diagnosis necessary prior to final impression (D6253) provided February 9, 2021.
You asked the Plan to pay for the provisional retainer crown and provisional pontic. You say that the dental procedures were related to a medical service and should be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 pay for the provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression (D6793) and provisional pontic - further treatment or completion of diagnosis necessary prior to final impression (D6253) provided February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing related to intraoperative neuromonitoring (IONM) provided on January 21, 2021, will with codes 95955, 95885, 95937, 95908, and 95927.
You asked the Plan to pay for the testing as billed. You say that these codes are all correct, and the services should be reimbursed. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 95908 is Nerve conduction studies; 3-4 studies. Lastly, 95927 is Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. 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 testing as billed. Our reviewer says that the services billed by these codes are not documented in the records provided. Our reviewer found for CPT 95955, the technical report documents "real time EEG monitoring was performed". This procedure would not be reported separately and is included in intraoperative neuromonitoring procedure. Therefore, this code would not be covered. For code 95908, the technical report describes pedicle screw stimulation, which is not a nerve conduction study, as it does not test amplitude, latency, and conduction velocity. Therefore, this code would not be covered. For CPT 95885, this code is an add-on code for nerve conduction studies, which were not documented as performed. Therefore, this code would not be covered. For CPT 95937, the technical report does not include documentation of neuromuscular junction testing; therefore, this code would not be covered. This appears to be used to report train of four testing which is not separately payable. For CPT 95927, the technical report does not include documentation of short-latency somatosensory evoked potential study, so this code can also not be confirmed as 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 testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic testing related to intraoperative neuromonitoring (IONM) provided on January 21, 2021, will with codes 95955, 95885, 95937, 95908, and 95927.