Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar disc injection at the 3rd level.

You asked the Plan to pre-approve a lumbar disc injection at the 3rd level. 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 one to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. 

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 lumbar disc injection at the 3rd level. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD limits the number of levels to be injected to 2 per session. Therefore, the third level is considered 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 a lumbar disc injection at the 3rd level have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar disc injection at the 3rd level.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Guardant360 testing (81479) provided on April 15, 2021.

You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied your request. The Plan says that it cannot be confirmed that the enrollee's physician ordered this testing.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that they were unable to confirm the order with the ordering provider. However, the provider they made outreach to is not the ordering physician listed on the claim and on the original order, which is included in the file. The Plan has also not provided reasoning for why the order in the file is not valid. Therefore, we decided that the Plan has to pay for Guardant360 testing (81479) provided on April 15, 2021.

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.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided November 10, 2020.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed 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 99214 is not supported in the medical record. Specifically, this service is included in the global surgery period for CPT 62323 which was also billed. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology and neuromuscular services represented by
codes 95861, 95868, 95927, 95938, and 95939, provided on September 10, 2020.
You asked the Plan to pay for the neurology and neuromuscular services. 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 claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The file shows that the neurology and neuromuscular services were
billed with POS code 15 for a mobile unit; however, the records show that the services were performed in a
facility setting. Therefore, we decided that the Plan does not have to pay for the neurology and neuromuscular
services represented by codes 95861, 95868, 95927, 95938, and 95939, provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eye exam (92015) provided April 2, 2021.
You asked the Plan to pay for routine eye exam. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim denied correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by a contracted vision provider. We looked at the file and the Plan's rules. In this case, the record confirms that the provider was not contracted with the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for routine eye exam (92015) provided April 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prosthetic device (L0457) provided February 12, 2021.
You asked the Plan to waive the coinsurance for the prosthetic device. You say that you believe that you are being over charged for this device. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 20% coinsurance for prosthetic devices and related supplies.
You have been asked to pay a total cost share of $159.73 for the prosthetic device ($798.63 Medicare-allowed amount x 20% coinsurance). This item falls 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 prosthetic device (L0457) provided February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation.

You asked the Plan to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation. 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 endovenous stents may be placed for patients with severely symptomatic venous obstructions. 

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 multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the documentation sent by the provider indicated that enrollee had been wearing compression hose to treat her varicose veins. The records did not describe any documented history of a blood clot in either leg. Both legs were described as having "mild" darkening, visible varicose veins, and being a little swollen (1+ in each foot) at the July 2, 2021 appointment. The review indicates that this enrollee did not meet the coverage criteria detailed in the LCD. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist services rendered on May 6, 2021.

You asked the Plan to waive the coinsurance for these services. You say that you should not have to pay. The Plan denied your request. The Plan says the coinsurance was 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 a 40% coinsurance for out-of-network specialist's office visits.

Review of the file shows that you received specialist services from an out-of-network provider on May 6, 2021. You have been asked to pay a 40% coinsurance for these services. These services fall within the out-of-network specialist's office visits 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 specialist services rendered on May 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab), 60 mg every 6 months for 1 year.
You asked the Plan to pre-approve Prolia. You say that the requested medication is medically necessary. The Plan denied your request. The Plan says the provider has not confirmed that the enrollee is supplementing with calcium and vitamin D. The Plan also says that the documentation does not support that the enrollee has a low blood calcium level.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab), 60 mg every 6 months for 1 year.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you have gum bleeding. You also say that this happens twice daily. The Plan denied your request. The Plan says the scaling and root planing is not medically necessary.
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 covers the dental services when the services are medically necessary and reasonable. 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 dental services.
Our reviewer says that the scaling and root planing for all 4 quadrants are not medically necessary. Our physician reviewer found the documentation provided does not meet the criteria for coverage for scaling and root planing of the 4 quadrants. The reviewer found that the charting of the periodontal pockets are within normal limits. The reviewer found that the radiographs show minimal bone loss and minimal calculus formation. Therefore, the reviewer found that the scaling and root planing for all 4 quadrants are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows that the periodontal pockets are within normal limits. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedures represented by codes 14301, 15740, 15004 and 14302 provided on August 28, 2020.
You asked the Plan to pay for codes 14301, 15740, 15004 and 14302. You say that the medical records support the billing of codes 14301, 15740, 15004 and 14302. The Plan denied your request. The Plan says the medical records do not support the billing of codes 14301, 15740, 15004 and 14302.
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 14301 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 15740 is Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel. 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. The definition of code 14302 is Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 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 codes 14301, 15740, 15004 and 14302. Our reviewer says that the medical records do not support the billing of codes 14301, 15740, 15004 and 14302. Our reviewer found the documentation submitted was reviewed and does not support the billing of codes 14301, 15740, 15004 and 14302. The operative report does not include enough documentation to confirm a secondary incision was made and an adjacent tissue transfer was performed, and not complex closure, therefore code 14301 cannot be verified. The operative report does not include enough information to confirm dissection of an anatomically named axial vessel, therefore, all description required to report CPT 15740 cannot be confirmed as performed. The operative report does not document a surgical preparation or creation of recipient site, unable to site due to no documentation of procedure, therefore code 15004 cannot be verified. The operative report does not document adjacent tissue transfer, as no secondary defect and adjacent tissue transfer was documented, therefore code 14302 cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 14301, 15740, 15004 and 14302 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedures represented by codes 14301, 15740, 15004 and 14302 provided on August 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visits provided on May 6, 2021 to May 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy visits. You say that you were unaware your doctor is not an approved Medicare provider. The Plan denied your request. The Plan says the provider is out-of-network
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 the psychotherapy visits provided on May 6, 2021 to May 20, 2021 by an out-of-network (OON) provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's current medical status does not require intensive physician and nursing oversight that can only be provided in an Inpatient Rehabilitation unit.
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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar spinal surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.