Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 20 additional outpatient physical therapy (PT) visits.  

You asked the Plan to pre-approve 20 additional outpatient PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  

The Plan must follow Medicare rules. The rules say that 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 20 additional outpatient PT visits.   

Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the additional requested 20 therapy sessions are not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program (HEP) and authorized additional therapy to ensure competence in a HEP. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 20 additional outpatient PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 20 additional outpatient physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog penfill.

You asked the Plan to pre-approve Novolog penfill. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog penfill.

Benefits for Novolog penfill may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (procedure code 99601) provided to the enrollee on May 28, 2021.

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 CPT code. 

In this case, the CPT Code Manual definition of code 99601 is "Home infusion/specialty drug administration, per visit (up to 2 hours)." 

We find that CPT code 99601 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 home infusion services (procedure code 99601) provided to the enrollee on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on July 23, 2021.

You asked the Plan to pay for the hearing aids. You say that you believed that because these services were 
provided within the Plan's medical network, they would be covered or reimbursed. You say that the Plan's 
customer service representative provided information for a few hearing providers, and you assumed the one 
you chose was among this group because they are part of the Plan's medical group. The Plan denied your 
request. The Plan says hearing aids must be purchased through the Plan's specified hearing vendor. The 
provider in question is not part of this specified group.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plan's specified hearing vendor network. 

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified routine 
hearing vendor group. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) 
purchased on July 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for psychotherapy services (90837) provided on January 11 to August 17, 2021.

You asked the Plan to waive the coinsurance for psychotherapy services. You say that the provider of the services at issue is an in-network provider. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 40% coinsurance for each Medicare-covered visit to an out-of-network provider for outpatient mental health care. 

In this case, the record does not support that the provider of the services at issue is an in-network provider. You
have been asked to pay less than or equal to 40% coinsurance for psychotherapy services. Psychotherapy services fall within the "Outpatient mental health care" benefit category. This means that you have been asked to pay less than or equal to 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 psychotherapy services (90837) provided on January 11 to August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cystourethroscopy provided on August 
4, 2021.

You asked the Plan to waive the deductible for this service. You say that you did not need this exam. The Plan 
denied your request. The Plan says that cost-sharing applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to outpatient surgery. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been 
met at the time this service was received on August 4, 2021. Therefore, we decided that the Plan does not have 
to waive the deductible for the cystourethroscopy provided on August 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 21, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81439, 81404) provided May 7, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The record shows these tests were not ordered by the enrollee's physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81439, 81404) provided May 7, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two prefabricated abutments (D6056 x2) and two abutment supported porcelain fused to metal crowns (D6059 x2) provided on June 29, 2021.

You asked the Plan to pay for the prefabricated abutments and abutment supported porcelain fused to metal crowns. You say that you received two crowns and they should have been covered. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two prefabricated abutments (D6056 x2) and two abutment supported porcelain fused to metal crowns (D6059 x2) provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) therapeutic procedure(s),
group (2 or more individuals) (97150) subcutaneous and intramuscular injection (96372) unclassified drug 
(J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) vitamin B-12 injection 
(J3420) provided May 7, 2021.

You asked the Plan to pay for the outpatient services. You say that please review the documents and reprocess 
this claim for payment. The Plan denied your request. The Plan says the Sanexas machine has not been shown 
to be beneficial and vitamin injections have not been show to be of any clinical utility in the management of 
neuropathic pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.

We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by a provider who is not licensed to provide 
physical therapy in the State of Wisconsin. The multiple drug codes reported on this claim refer to a pre-filled 
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not 
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. 
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on 
this information, we decided that Medicare rules for coverage of the outpatient services have not been met.
Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) therapeutic 
procedure(s), group (2 or more individuals) (97150) subcutaneous and intramuscular injection (96372) 
unclassified drug (J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) vitamin B12 injection (J3420) provided May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by participating 
and nonparticipating provider on May 24, 2021, to July 7, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $40 
copayment for outpatient rehabilitation services. 

You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked 
to pay is $200 ($40 x 5 visits = $200). Physical therapy falls within the outpatient rehabilitation services 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 physical therapy provided by a participating 
and nonparticipating provider on May 24, 2021, to July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99283) provided May 28, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 99283
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for physician services (99283) provided May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric (psych) services provided from June
24, 2021, to June 30, 2021.
You asked the Plan to pay for the inpatient psych services. You say that the services should be covered. The
Plan denied your request. The Plan says the services were 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 pay for the inpatient psych services. Our reviewer
says that the inpatient psych services were not medically necessary. Our physician reviewer found the provided
records indicate that it was not expected this enrollee would improve in a reasonable period of time as he did
not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any
behavioral issues. 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 as he did not have dangerousness to self or others,
perceptual disturbance including delusions, auditory or visual hallucinations. The reviewer found that the
enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others
and was cooperative and compliant. The reviewer found that active treatment was not taking place. The
reviewer also found that the services were not reasonably expected to improve the enrollee's condition or for
the purpose of diagnosis. Therefore, the reviewer found that the inpatient psych services were not medically
reasonable or 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 inpatient psych services have not been met. Specifically, the file shows that
the enrollee was not a danger to themself or others. Therefore, we decided that the Plan does not have to pay
for the inpatient psychiatric (psych) services provided from June 24, 2021, to June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation (97112), manual therapy techniques (97140), and therapeutic activities (97530) provided from July 7, 2021, to July 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the therapeutic exercises, neuromuscular reeducation, manual therapy techniques, and therapeutic activities. You say that a Plan representative advised that authorization was not required. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider and were not authorized by the Plan. The Plan also says that the Plan advised the caller that a referral for physical therapy is required and that there was no referral on file when the Plan was contacted.
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 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 therapeutic exercises (97110), neuromuscular reeducation (97112), manual therapy techniques (97140), and therapeutic activities (97530) provided from July 7, 2021, to July 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213), the tangential biopsy of skin (11102), the destruction of premalignant lesions (17000, 17003), the repair, intermediate, of the wounds of the face, ears, eyelids, nose, lips and/or mucous membranes (12052), and the excision of a malignant lesion (11641) rendered by the out-of-network (OON) provider on July 20, 2021 and August 17, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99213), the tangential biopsy of skin (11102), the destruction of premalignant lesions (17000, 17003), the repair, intermediate, of the wounds of the face, ears, eyelids, nose, lips and/or mucous membranes (12052), and the excision of a malignant lesion (11641) rendered by the out-of-network (OON) provider on July 20, 2021 and August 17, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary, as improvement has been made with daily therapy. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF coverage.
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 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. You do not require skilled nursing or therapy services on a daily basis. You do 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 Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on March 26,
2021.

You asked the Plan to pay for discharge day management. You say that this should be covered. The Plan
denied your request. The Plan says this is not supported in the records.

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 99239 is hospital discharge day management; more than
30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent on this service
is not documented. Based on this information, we decided that Medicare rules for coverage of discharge day
management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day
management (99239) provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and staff (99072) provided March 11, 2021.

You asked the Plan to pay for the additional supplies and staff. You say that the services were medically necessary. The Plan denied your request. The Plan says this code is not separately payable.

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 99072 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "B". Payment for this service is always bundled with another service. Based on this information, we decided that Medicare rules for coverage of the additional supplies and staff have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies and staff (99072) provided March 11, 2021.