Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (HCPCS S9502) provided to the enrollee from November 23, 2020 to December 29, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure for this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that HCPCS code S9502 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 (HCPCS S9502) provided to the enrollee from November 23, 2020 to December 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical therapy evaluation with an out-of-network provider.

You asked the Plan to pre-approve the physical therapy evaluation. You say that this is close to your house, you've had services here before and you know they can help you. The Plan denied your request. The Plan says in-network providers are available.

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. Therefore, we decided that the Plan does not have to pre-approve a physical therapy evaluation with an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy (PT) visits.

You asked the Plan to pre-approve the additional PT visits. You say that the medical records provided should support the medical necessity of the service in dispute. The Plan denied your request. The Plan says the available medical records do not support necessity of the service as defined by Medicare criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the available records the patient appears to have improved with therapy to the point of being able to manage his activities of daily living. Further skilled therapy beyond the approved 30 visits does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. Further utilization of the home exercise program appears appropriate after completion of the 30 physical therapy visits.

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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of an inpatient hospital stay provided from November 30, 2020, through December 1, 2020.

You asked the Plan to pay for continuation of an inpatient hospital stay. The Plan denied your request. The Plan says the enrollee does not meet criteria for inpatient stay. Continued care (including intravenous antibiotics) can be provided at a lower level, such as acute or subacute rehabilitation.

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 continuation of an inpatient hospital stay. Our reviewer says that the requested inpatient hospital stay is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was a then, a 67-year-old female with left middle cerebral artery (MCA) stroke, asthma, Type 2 diabetes, admitted with a fever from a skilled nursing facility. The review indicates that on November 30, 2020 and December 1, 2020 the member was clinically stable; vital signs stable; labs stable; she did not appear to have recurrent active C-diff; stools more formed; receiving nutrition (and medications) through a stomach tube without any problems. The review indicates that the ongoing inpatient care on November 30, 2020 and December 1, 2020 was not medically reasonable and necessary and the enrollee could have been discharged to a lower level of care. During the hospital days in question the member did not require or receive any inpatient diagnostic studies or therapeutic interventions.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of an inpatient hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for continuation of an inpatient hospital stay provided from November 30, 2020, through December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) thorax, and abdomen and pelvis.

You asked the Plan to pre-approve Computed tomography, thorax, diagnostic; with contrast material(s) (71260) and Computed tomography, abdomen and pelvis; with contrast material(s) (74177). You say that you are requesting the CTs to ensure that there has been no progression of disease. Plan denied your request. The Plan says the clinical information provided does not describe signs, symptoms or lab results suggesting cancer recurrence or progression.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Computed tomography, thorax, diagnostic; with contrast material(s) (71260) and Computed tomography, abdomen and pelvis; with contrast material(s) (74177). Our reviewer says that the CTs are not medically necessary. Our physician reviewer found surveillance CT chest abdomen/pelvis not clinically indicated. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Computed tomography, thorax, diagnostic; with contrast material(s) (71260) and Computed tomography, abdomen and pelvis; with contrast material(s) (74177) have not been met.

Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) thorax, and abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leg prosthesis and related supplies provided on December 18, 2020.

You asked the Plan to waive the coinsurance for the leg prosthesis and related supplies. You say that the leg does not fit and does not work. You say that the provider said you would only have to pay $350. The Plan denied your request. The Plan says the coinsurance 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered prosthetic devices, related supplies, and services from an in-network provider.

You have been asked to pay $1,599.12, which is 20% of the allowed amount for the leg prosthesis and related supplies. The allowed amount is $7,995.62 (20% x $7,995.62 = $1,599.12). The leg prosthesis and related supplies fall 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 the leg prosthesis and related supplies provided on December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the follow up-visit to be provided by an out-of-network provider.

You asked the Plan to pre-approve the follow up-visit. You say that you want to continue with this provider only. The Plan denied your request. The Plan says an in-network radiation oncologist can safely provide the requested service.

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. Therefore, we decided that the Plan does not have to pre-approve the follow up-visit to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve massage therapy. You say that you would like to go ahead and have massage therapy. You would rather not have surgery with long recovery and PT and nursing. You feel this would be much cheaper for yourself and the plan in the long run. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the IPACK block provided on June 9, 2020, for postoperative pain
management after a knee surgery, billed with code 64999-59-LT.
You asked the Plan to pay for the IPACK block. You say that these services are separately payable and should
be reimbursed in full. The Plan denied your request. The Plan says that procedure code 64999 should not be
billed by an anesthesia practitioner per NCCI policy, chapter 2. Anesthesia services must be billed with 00100-
01999 when billed by an anesthesia practitioner.
The Plan must follow Medicare rules. Medicare rules say that while anesthesia services in themselves are billed
with a code in the 0XXXX range, separate reporting and payment is allowed for procedure performed for
postoperative pain management when requested by the surgeon.
In this case, there is documentation that the surgeon requested an adductor nerve block as well as an IPACK
block for postoperative pain control. The narrative section of this claim confirms that 64999 was used to report
the IPACK block. The Plan has made payment for the adductor block coded as 64447. According to the
Current Procedure Terminology (CPT) Assistant from the American Medical Association (AMA), Volume 30,
Issue 6, "The IPACK block is directed at a tissue plane, not at a specific nerve. Currently, there is no specific
CPT code to report an IPACK block. Therefore, code 64999, Unlisted procedure, nervous system, should be
reported." As such, use of this code to report the postoperative pain control injection is supported. Therefore,
we decided that the Plan has to pay for the IPACK block provided on June 9, 2020, for postoperative pain
management after a knee surgery, billed with code 64999-59-LT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health care.

You asked the Plan to pre-approve this service. You say that inpatient behavioral health care is medically
necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 this service.

Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that
based upon the records provided, it was not expected that this enrollee would improve in a reasonable period of
time beyond the date in question as he was not showing any dangerousness to self or others, there were no
auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and
did not have side effects to the medication. It did not appear medically necessary and reasonable to have
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the date in
question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. It did
not appear that active treatment was taking place beyond the date in question. It did not appear that the services
for the date in question were reasonably expected or medically necessary to improve the patient's condition or
were for the purpose of a diagnosis. Based upon the review of the records provided, this patient does not meet
the criteria for coverage of acute inpatient mental health treatment beyond the date in question of June 2, 2021.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued inpatient behavioral health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips that go beyond the allotted 48 trip limit.

You asked the Plan to pre-approve additional trips. You say that you need additional rides to appointments. The Plan denied your request. The Plan says there is no exception that would allow the Plan to cover additional rides.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips that go beyond the allotted 48 trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth #7.

You asked the Plan to pre-approve endodontic therapy. You say that this service is necessary. The Plan denied
your request. The Plan says this service is not covered by the Plan's dental benefit.

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. The Plan does not cover
endodontic services.

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
endodontic therapy (D3310) for tooth #7.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says IRF care is not medically necessary.

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 was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer remains experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.

You asked the Plan to provide a therapeutic continuous glucose monitor system. You say that the enrollee is unable to test by finger due to poor circulation and pain. The Plan denied your request. The Plan says criteria is not met for a therapeutic continuous glucose monitor system.

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. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor system have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.