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

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on August 10, 2021.

You asked the Plan to pay for the transportation services. You say that the could not have been safely transported by any other means. The Plan denied your request. The Plan says the transportation services are not medically necessary.

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 the transportation services. Our reviewer says that the non-emergency ambulance transportation services were not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee was transferred from an inpatient psychiatric facility to a skilled nursing facility. The documentation provided is insufficient to establish that other means of transportation were contraindicated or that the enrollee's condition is such that other means of transportation could endanger their health. Therefore, the reviewer found that the non-emergency ambulance transportation 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 transportation services have not been met. Specifically, the file does not indicate that that other means of transportation were contraindicated or that the enrollee's condition is such that other means of transportation could endanger their health. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardioversion rendered on June 2, 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 92960 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. 

In this case, the CPT Code Manual definition of code 92960 is cardioversion, elective, electrical conversion of arrhythmia; external. 

We find that CPT code 92960 is not supported in the medical record. Specifically, there is no documentation of elective external cardioversion. 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 cardioversion rendered on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 out of network physician services provided to the enrollee on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (01924) provided on May 17, 2021.

You asked the Plan to pay for code 01924. 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.

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 01924 is Anesthesia for therapeutic interventional 
radiological procedures involving the arterial system; not otherwise specified.

We find that CPT code 01924 is not supported in the medical record. Specifically, an appropriate surgical 
procedure code that crosswalks with the billed anesthesia code was not reported. Based on this information, we 
decided that Medicare rules for coverage of code 01924 have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (01924) provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services (95938, 95940, 95939) provided on June 15, 2020.
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration because payment is not the responsibility of the facility. The Plan denied your request. The Plan says this provider is not a recognized facility or a legally qualified physician and billing agents and third party vendors do not fall within the category of eligible providers.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Specifically, payment for the neuromonitoring services is included in the payment to the facility and is the responsibility of the facility to any vendor. Additionally, the place of service code should represent the facility which this mobile unit is serving. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services (95938, 95940, 95939) provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve a 1 month supply of Contour next test strips. We decided that the
Plan does not have to pre-approve Contour next test strips beyond the 1 month supply.
You asked the Plan to pre-approve a 1 month supply of Contour next test strips. You say that the items are
necessary. The Plan says that based on the documentation provided, coverage criteria has not been met.
We decided that the Plan has to pre-approve a 1 month supply of Contour next test strips.
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers.
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 1 month supply of Contour next test
strips. Our reviewer says that the items are medically necessary. Our physician reviewer found if the enrollee
were to be denied strips now required for blood glucose testing, it would be dangerous. Providing strips for 1
month (i.e. 120 strips) of the contour next brand would be appropriate and 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 a 1 month supply of Contour next test strips have been met. Therefore, we
decided that the Plan has to pre-approve a 1 month supply of Contour next test strips.
We also decided that the Plan does not have to pre-approve Contour next test strips beyond the 1 month
supply.
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers.
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 Contour next test strips beyond the 1
month supply. Our reviewer says that the items are not medically necessary. Our physician reviewer found over
the course of the next month, the enrollee's doctor and/or the enrollee should be able to determine the correct
brand of meter and strips (i.e. accuchek or one touch) and get those prescribed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Contour next test strips beyond the 1 month supply have not been met.
Therefore, we decided that the Plan does not have to pre-approve Contour next test strips beyond the 1 month
supply.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient stay provided from May 11, 2021, to May 12, 2021.

You asked the Plan to pay for the inpatient stay. You say that the services provided are documented and support the need for inpatient care. The Plan denied your request. The Plan says this request does not meet the criteria for a continued inpatient stay. The Plan also says that further care could be provided at a lower level.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient stay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is an 89-year-old female with a recent humerus fracture, urinary tract infection, and altered mental status admitted and treated for such but complicated by cardiac arrest which led to requiring mechanical ventilation, trach placement, percutaneous endoscopic gastrostomy placement, and intravenous (IV) antibiotics. Our reviewer found that recent notes show the patient having completed IV medications, tolerated tube feeds, stable ventilation settings, and improving leukocytosis. Continued inpatient care from May 11, 2021, to May 12, 2021 was requested. Vitals were normal from May 11, 2021. Our physician reviewer also found that there was no indication the patient could not have been treated at a lower level of care from May 11, 2021, to May 12, 2021 as she was hemodynamically stable and was improving with treatment. 

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 stay have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient stay provided from May 11, 2021, to May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the multi-axial ankle rendered on November 30, 2020.

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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that the expectation of functional ability information must be clearly documented and retained in the prosthetist's records. 

We looked at the file and Medicare rules. The file shows that code L5979 (multi-axial ankle) with K2 for functional level 2; however, there is no supporting documentation to clearly show that the K2 ambulation level is met. 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 multi-axial ankle rendered on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 8, 2021.
You asked the Plan to pay for the dental services. You say that you were informed this provider was in-network when you signed up with the Plan. The Plan denied your request. The Plan says out-of-network dental 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on September 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 15, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 out of network physician services provided to the enrollee on February 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the bladder irrigation services coded 51700 and the surgical trays coded A4550 provided on January 29, 2021.

You asked the Plan to pay for the bladder irrigation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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. In this case, we have confirmed that code 51700 for the bladder irrigation services is a column II code to column I code 52000. 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. We find that CPT code A4550 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that payment for these services is always bundled into payment for other services not specified. This code is not separately payable. Therefore, we decided that the Plan does not have to pay for the bladder irrigation services coded 51700 and the surgical trays coded A4550 provided on January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel 
to home or nursing home, per trip to facility or location (R0070), the x-ray exam of the ankle (73610), and the 
set-up of portable x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on June 1, 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 transportation of portable x-ray equipment and personnel to home or nursing 
home, per trip to facility or location (R0070), the x-ray exam of the ankle (73610), and the set-up of portable 
x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203) provided on August 13, 
2021.

You asked the Plan to pay for a chiropractic office visit. You say that you need chiropractic care, and it has 
been covered by other insurance in the past. The Plan denied your request. The Plan says this is not covered by 
Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99203) provided on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 28, 2020 to October 4, 2020.
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 submitted records do not support the billing of DRG 871 and diagnosis codes A41.81 and A41.9.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871, primary diagnosis A41.81 (sepsis due to enterococcus), and secondary diagnosis A41.9 (sepsis, unspecified organism). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 871 and diagnosis codes A41.81 and A41.9. Our physician reviewer found the records support an admission for pneumonia and inconsistent regarding a diagnosis of sepsis. Even though sepsis is documented in the history and physical, progress notes, and discharge summary, supporting medical record documentation was not found within the record. Elevated heart rate, temperature, and white blood cell counts are noted upon presentation but the values promptly improved with treatment in the emergency department. There is no evidence of significant physiologic instability. The records therefore do not support the billing of primary diagnosis A41.81 and secondary diagnosis. A41.9. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from September 28, 2020 to October 4, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT scan of the head or brain (70450) provided on July 19, 2020.

You asked the Plan to pay for a CT scan of the head or brain. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.

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. Specifically, the Plan has denied this service stating that payment for procedure code 70450 is included in the payment of procedure code 70496. The Plan has not forwarded any evidence that procedure code 70496 was billed on the same date of service. The Plan has not provided additional evidence to indicate why procedure code 70450 cannot be paid. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for a CT scan of the head or brain (70450) provided on July 19, 2020.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 15, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation submitted is missing required information.

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. 

Review of the file shows that the ordering physician's progress notes were requested by the Plan and were not provided. These progress notes are required in order to determine the clinical utility of the testing. This means that the documentation does not support that the test at issue in this appeal was not 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 drug testing coded G0483 provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651 NU) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code(s): E0667 NU RT and E0667 NU LT) provided to the enrollee on April 26, 2021.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. According to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician as required per CMS guidelines. In addition, documentation submitted did not sufficiently support the billed supply code. Therefore, we decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651 NU) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code(s): E0667 NU RT and E0667 NU LT) provided to the enrollee on April 26, 2021.