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

We decided that the Plan does not have to pay for continuation of SNF services provided from March 11, 2021, through April 11, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care 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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of March 11, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of March 11, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, his function had plateaued by March 11, 2021 and he did not require any further inpatient skilled rehab services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of March 11, 2021 the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from March 11, 2021, through
April 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 15, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 15733 and 15004 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae).
The definition of code 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. We find that procedure codes 15733 and 15004 are not supported in the medical record. Specifically, there is no documentation of a muscle, myocutaneous, or fasciocutaneous flap of the head or neck to support code 15733. There is no documentation of surgical preparation or creation of recipient site by excision to support code 15004. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional OT visits.
You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional occupational therapy would improve the enrollee's independence. You say the enrollee needs assistance with feeding and grooming and her splint placement as well. The Plan denied your request. The Plan says additional OT is not medically necessary.
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 ten (10) additional OT 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 in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not 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 ten (10) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis rendered on May 15, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 74177 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 74177 (CT abdomen/pelvis without contrast) and 74178 (CT abdomen/pelvis with contrast). Code 74177 is a column II code with a modifier indicator of 1 when billed
with column I code 74178. Code 74177 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen/pelvis rendered on May 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a vitamin assay panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 24, 2021 by an out-of-network (OON) provider.
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 services rendered by non-participating providers require prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on February 24, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation
is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
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 60 one-way transportation 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 routine transportation.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injections (62321).
You asked the Plan to pre-approve the epidural steroid injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the epidural steroid injections. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found MRI shows disc protrusions at C3-C4 and C4-C5 as well as degenerative disc changes at multiple levels. Cervical epidural steroid injections are administered at C7-T1 or C6-C7 as a standard of care because the ligamentum flavum is not always fused above these levels. The request is medically reasonable and 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 epidural steroid injections have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injections (62321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on February 22, 2021.
You asked the Plan to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (99100). You say that the Plan should pay this
claim. The Plan denied your request. The Plan says code 99100 has a status indicator of B and is always bundled into payment for other services.
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, we have confirmed that code 99100 has a Status Indicator of B, Bundled Code. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional epidural steroid injections.
You asked the Plan to pre-approve 2 additional epidural steroid injections. 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 follows Medicare rules. Medicare rules say that if a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50% symptom improvement, insignificant or indiscernible relief), a second epidural injection utilizing the same method, technique or medication to the same level will be considered not medically reasonable and 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 2 additional epidural steroid injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the plan has approved one right cervical C4-C5 epidural steroid injection. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD for additional epidural steroid injections. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 2 additional epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional epidural steroid injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on June 3, 2021, by an in-network provider.
You asked the Plan to waive the copayment for the laboratory services. You say that the provider did not tell you that you would be billed for $2. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received laboratory services on June 3, 2021, by an in-network provider. You were asked to pay a $2 copayment for the laboratory services. Your 2021 EOC states that enrollees must pay a $2 copayment for in-network Medicare-covered labs. 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 laboratory services provided on June 3, 2021, by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (A4233 and A4253) provided to the enrollee on September 3, 2020.
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says the required DME modifiers should be submitted.
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 Healthcare Common Procedure Coding System (HCPCS) codes A4233 and A4253 are not supported in the medical record. Specifically, these codes must be billed with a modifier of "NU". Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4233 and A4253) provided to the enrollee on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter placement in coronary artery(s) for coronary
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and
interpretation represented by code 93454-26-59 provided on October 8, 2020.
You asked the Plan to pay for code 93454-26-59. You say that the medical records support the billing of code
93454-26-59 provided on October 8, 2020. The Plan denied your request. The Plan says the medical records do
not support the billing of code 93454-26-59 provided on October 8, 2020.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
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 code 93454-26-59 Our reviewer says that the
medical records do not support the billing of code 93454-26-59 provided on October 8, 2020. Our physician
reviewer found the coronary angiography (93454) was part of the stenting/PCI procedure and was not a distinct
or different procedure or surgery but is encompassed within the PCI/stenting procedure. A full left heart
catheterization with LV pressure measurements and left ventriculography was not done. Only pre-stent
coronary visualizations by angiography were done as is necessary to make a determination of coronary
anatomy prior to stenting. As such it would not be considered a separate procedure, surgery, patient encounter,
organ system or surgical site based on the applicable CMS billing rules and would not be separately
reimbursable. The pre-stent coronary angiography is encompassed within the PCI/stent procedure and billing
code.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 93454-26-59 have not been met. Therefore, we decided that the Plan does
not have to pay for the catheter placement in coronary artery(s) for coronary angiography, including
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation represented by
code 93454-26-59 provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on March 29, 2021.
You asked the Plan to pay for code 97530. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 97530 is Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation submitted includes an occupational therapy home visit for the billed date of service. CPT code 97530 is the incorrect code
to report for this service and should be reported with a more appropriate Healthcare Common Procedure Coding System (HCPCS) code. Based on this information, we decided that Medicare rules for coverage of code 97530 have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on March 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a folding wheeled walker (E0143), commode chairs (E0163), and bedside rails (E0310) provided on April 20 to May 14, 2021, by a supplier who is not enrolled in the Medicare program.
You asked the Plan to pay for a folding wheeled walker, commode chairs, and bedside rails. You say that the requested items were a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met because the supplier in this case is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a folding wheeled walker (E0143), commode chairs (E0163), and bedside rails (E0310) provided on April 20 to May 14, 2021, by a supplier who is not enrolled in the Medicare program.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the maxillofacial area (70486).
You asked the Plan to pre-approve a CT scan of the maxillofacial area. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 a CT scan of the maxillofacial area. Our reviewer says that the services are medically necessary. Our physician reviewer found an endoscopy on September 1, 2021 revealed a difficult to drain frontal sinus. A followup CT to assess the residual sinus disease is reasonable and 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 a CT scan of the maxillofacial area have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the maxillofacial area (70486).
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.