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

 We decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on June 4, 2021.  You asked the Plan to pay for the adjacent tissue transfer (14301 and 14302). You say that you are submitting documentation to support CPT code 14301 and 14302. You say that the documentation should be reviewed and reprocessed for payment. The Plan denied your request. The Plan says the records do not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.     In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual 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 the adjacent tissue transfer (14301 and 14302). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that an adjacent tissue transfer or rearrangement is flat sections of healthy skin and other tissues transferred or transplanted to the area adjacent to a skin defect. Our reviewer says that the operative report does not support adjacent tissue transfer or arrangement.  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 adjacent tissue transfer (14301 and 14302) have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound repair (12052) provided on May 11, 2021.  You asked the Plan to pay for the wound repair (12052). You say that the patient underwent a surgical excision, and a skin graft was required for the defect. You say that both Medicare and the Plan have agreed immediate repair is billable and the claim should be reprocessed for additional payment. The Plan denied your request. The Plan says this code is included in CPT code 15260 and cannot be separately reimbursed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  In this case, the CPT Code Manual definition of code 12052 is repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm.  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 wound repair (12052). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not support the use of modifier 59 in this case, as CPT instructs that harvesting and repairing the skin graft donor site is included in the skin graft code. Therefore, layered closure should not be reported separately.  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 wound repair (12052) have not been met. Therefore, we decided that the Plan does not have to pay for the wound repair (12052) provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ondansetron tablets.  

You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  

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. Although an oral anti-emetic such as ondansetron may sometimes be covered by Medicare Part B, these circumstances are not included in Part B coverage because the requested use of ondansetron does not meet the timeframe requirements and is not being used as a full therapeutic replacement for intravenous anti-emetics that would have been administered as the time of chemotherapy. Therefore, we decided that the Plan does not have to pre-approve ondansetron tablets.   

Benefits for self-administered drug 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: Favorable

 We decided that the Plan has to pay for the surgical services provided on June 29, 2021.  

You asked the Plan to pay for the surgical services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.  

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. In this case, the Plan has not provided any supporting evidence showing that the claim was not submitted correctly for payment per Medicare guidelines. The provider has the correct credentials for the services performed per Medicare guidelines. The Plan denied payment due to the taxonomy code not being found on the crosswalk. However, the Plan provided no evidence showing that services were billed incorrectly per Medicare guidelines. Therefore, we decided that the Plan has to pay for the surgical services provided on June 29, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2021.  

You asked the Plan to pay for the laboratory 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 separately payable.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 88191, 81371, 81295, and 81298 provided on April 26, 2021
.  
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 provided are not a covered benefit.  

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 88191, 81371, 81295, and 81298 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 an office setting, place of setting 11. 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 88191, 81371, 81295, and 81298 provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a second opinion with an out-of-network provider.  You asked the Plan to pre-approve a second opinion with an out-of-network provider. You say that the requested second opinion with an out-of-network provider is medically necessary. The Plan denied your request. The Plan says the requested second opinion with an out-of-network provider is not medically necessary.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 second opinion with an out-of-network provider. Our reviewer says that the requested second opinion with an out-of-network provider is not medically necessary. Our physician reviewer found based on the documentation provided, the Plan's denial is medically justified on the basis that the Plan is offering adequate care to meet the enrollee's medical needs through referral to an in-network oncologist. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. The enrollee can be safely seen by an in-network provider.  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 second opinion with an out-of-network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a second opinion with an out-of-network provider.
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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis as needed appear appropriate in this case.  

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 pre-approve a group three power wheelchair (k0861) and accessories.  

You asked the Plan to pre-approve a group three power wheelchair and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the member has a group three power wheelchair that is less than 5 years old.  

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years.  

The file shows that the enrollee has a group three power wheelchair. The requested item serves the same purpose as the item the enrollee currently has. As the member does not qualify for the wheelchair base, none of the requested accessories can be covered. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair (k0861) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  July 22, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  

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 $30 copayment for each Medicare-covered specialist visit.   

You have been asked to pay a $30 copayment for the Medicare-covered specialist visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99213) provided on July 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 18 home health skilled nursing visits.  

You asked the Plan to pre-approve home health skilled nursing services. You say that these home health services are medically necessary. The Plan denied your request. The Plan says the criteria for home health services have not been met.  

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 home health skilled nursing services. Our reviewer says that the requested home health skilled nursing services are not medically reasonable and necessary. Our physician reviewer found you are noted to have bilateral lower extremity edema, for which twice weekly dressings are ordered. There is no evidence of open wounds. The edema appears to be chronic. It is unclear when the dressings were initiated. You are noted to have an available caregiver. It is unclear if the caregiver has received or failed dressing education. The documentation does not establish that skilled nursing in medically necessary to provide the ordered services.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laparoscopy (38570) provided on July 26, 2021.  You asked the Plan to pay for the laparoscopy (38570). You say that there are no bundling issues found and the code should be reprocessed. The Plan denied your request. The Plan says CPT code 38570 is not supported in the documentation therefore is not 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, the CPT Code Manual definition of code 38570 is laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple.     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 laparoscopy (38570). Our reviewer says that the procedure report does include enough detail to verify a lymphadenectomy was performed through separate incision, to confirm this procedure is separate from CPT 43235.   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 laparoscopy (38570) have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy (38570) provided on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit.  

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 not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of anemia due to sickle cell disease and clinically cured lung cancer, not receiving myelosuppressive chemotherapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  Retacrit is therefore not medically necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need assistance to have a better quality of life. The Plan denied your request. The Plan says that your records do not show that you require skilled nursing or therapy services on a daily inpatient basis.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).  

You asked the Plan to pre-approve therapeutic CGM. You say that you test your diabetes 4 times per day. The Plan denied your request. The Plan says you do not meet the coverage criteria for a therapeutic CGM.  

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   

We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your treating physician to assesses adherence to a CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the molecular genetic screening testing provided on August 30, 2021.  You asked the Plan to pay for the molecular genetic screening testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The molecular genetic screening testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular genetic screening testing provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services provided on January 27, 2021.  

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. The records show that the physical therapy services at issue were performed by a physical therapy assistant. There is a more comprehensive code to describe the services provided.  

Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on January 27, 2021.