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

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 16, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a nursing facility place of service 32.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says it appears that the current formal therapy should meet clinical expectations with the eighteen total approved visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition, beyond what was approved by the health plan. You have had prior therapy, 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. The requested services are not part of a maintenance program. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health physical therapy visits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on December 11, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reprocessed for payment because the paid amount was recouped in error. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser treatment services provided on November 24, 2020.
You asked the Plan to pay for the laser treatment services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
We looked at the file and Medicare rules. Review of the file shows that medical records for the services
rendered were not provided for review. There is no documentation in the case file to support that the services
rendered were not for cosmetic purposes. Based on this information, we decided that Medicare rules for
coverage of the laser treatment services have not been met. Therefore, we decided that the Plan does not have
to pay for the laser treatment services provided on November 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
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 Synvisc. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc (J7325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Vancomycin 125 mg capsule.
You asked the Plan to pre-approve Vancomycin capsule. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Vancomycin 125 mg capsule.
Benefits for Vancomycin capsule 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on November 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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. 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 services. Our reviewer says that the use of code 97110 is not supported by the records provided. Our reviewer found that the documentation includes a therapy visit performed by a physical therapy assistant in the home setting. CPT 97110 is an incorrect code to report for this service. A home visit should be reported with the appropriate Healthcare Common Procedure Coding System (HCPCS) code.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97110) provided on November 18, 2019
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core buildups (D2950 x2), and a retainer crown (D6751).

You asked the Plan to pre-approve a crown, core buildups, and a retainer crown. You say that the services at issue are necessary. The Plan denied your request. The Plan says the crown is a covered benefit, but you have exceeded the frequency limit of one every year. The retainer crown and core buildups are not covered services.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown, core buildups, and a retainer crown have not been met. Specifically, the Plan pre-approved one crown and therefore, additional crowns are not covered as it exceeds the frequency limit of 1 crown per year. Additionally, retainer crowns and core buildups are not covered services. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), core buildups (D2950 x2), and a retainer crown (D6751).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the request for anticipated payment (RAP) filed with date of service October 29, 2020.
You asked the Plan to pay for the RAP. The Plan denied your request. The Plan says the final claim was not received within the required time frame per the Medicare Guidelines.
The Plan must follow Medicare rules. Medicare rules say that if the claim is not received 120 days after the start date of the episode or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by Medicare claims processing systems.
We looked at the file and Medicare rules. This RAP was submitted in December 2020, and the first portion of the payment was made on January 11, 2021. The claim needed to be submitted before March 12, 2021 to avoid the RAP being recouped. The documentation shows that the claim was not submitted until May 2021. Based on this information, we decided that Medicare rules for coverage of the RAP have not been met. Therefore, we decided that the Plan does not have to pay for the request for anticipated payment (RAP) filed with date of service October 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says six visits can be approved to finalize a home exercise program.
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 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy, 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. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).

You asked the Plan to pre-approve the device. You say that this is medically necessary to help with knee pain
after surgery. The Plan denied your request. The Plan says this is a preventive service and is excluded from
coverage.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with
venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb
compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), three additional intraoral periapical x-rays (D0230 x3), and topical application of fluoride varnish (D1206) provided on April 26, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, and topical application of fluoride varnish. You say that these services were obtained by a staff dentist of the facility who has not opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective January 20, 2016, to January 20, 2022.
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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), three additional intraoral periapical x-rays (D0230 x3), and topical application of fluoride varnish (D1206) provided on April 26, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic device repairs from an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 prosthetic device repairs from an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty surgery.

You asked the Plan to pre-approve kyphoplasty. You say that the enrollee needs this procedure due to a compression fracture. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not medically necessary.

The Plan follows Medicare rules. Medicare rules state that kyphoplasty may be covered for enrollees who meet appropriate inclusion criteria and do not meet any of the specified exclusion criteria.

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 kyphoplasty. Our reviewer says that the enrollee does not meet the Medicare criteria for kyphoplasty. Our physician reviewer found there is no imaging study showing that this is a recent vertebral compression fracture.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation provided on April 24, 2021.

You asked the Plan to pay for ambulance transport. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was stable and could have been transported by another type of vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance transport. Our reviewer says that this transport does not meet the Medicare criteria for coverage. Our physician reviewer found the documentation does not support that other means of transport (such as a stretcher or wheelchair van) were contraindicated for the enrollee. The documentation does not support that the enrollee needed the expertise, services, and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The enrollee was stable and did not require any treatment during transport.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation provided on April 24, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the arm joint for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the doctor needs to send a new request with supporting notes showing the need for the MRI.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found plain x-rays were done on 9/21/21 and showed only minimal degenerative changes in the acromioclavicular (AC) joint. The x-rays were otherwise negative. A detailed physical exam and reasons for requesting this MRI were available in the submitted records. The enrollee's activities of daily living are severely affected by pain. The orthopedic specialist says that the physical findings support a diagnosis of rotator cuff insufficiency, and MRI is the requested to determine if physical therapy makes sense rather than consideration of surgery.
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the arm joint for the enrollee.

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.