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

We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing (88121) provided on August 12, 2021.
You asked the Plan to pay for the diagnostic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the testing is not covered for the enrollee's diagnosis.
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay. 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 diagnostic testing. Our reviewer says that the diagnostic testing is not medically necessary. Our physician reviewer found the FISH (fluorescence in situ hybridization) testing is not a Medicare benefit for the diagnosis listed on the claim. The reviewer found that bladder cancer tumor markers performed by any technology immunoassay, molecular or FISH testing, are not covered for screening of all patients with hematuria. The reviewer found that urine cytology is not considered a bladder tumor marker. Therefore, the reviewer has determined that the FISH testing is 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 diagnostic testing have not been met. Specifically, the FISH testing is not a Medicare benefit for the diagnosis listed on the claim. Therefore, we decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing (88121) provided on August 12, 2021.
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 you need inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography coded as 95868 provided on March 5, 2021.
You asked the Plan to pay for the needle electromyography. You say that the documentation provided supports the claim as billed. The Plan denied your request. The Plan says the documentation does not support the code as 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 95868 is needle electromyography (EMG); cranial nerve
supplied muscles, bilateral. 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 needle electromyography. Our reviewer says that the medical documentation does not support the service as billed. Our reviewer found that the procedure report documents that "Needle EMG: 1 Extremity (4 or less muscles tested in an extremity) (2 units) - Muscles Monitored: Deltoid/Biceps, Triceps, Abductor Pollicis Brevis/Abductor Digiti Minimi". EEG for cranial nerve supplied muscles, bilateral is an incorrect procedure code to report for this service. Documentation does not include documentation of EMG cranial nerve supplied muscles. 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 needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography coded as 95868 provided on March 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation (90791) provided on March 7, 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 $40 copayment for each Medicare-covered individual session for outpatient mental health services provided by a psychiatrist.

You have been asked to pay a $40 copayment for the Medicare-covered outpatient mental health service 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 psychiatric diagnostic evaluation (90791) provided on March 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough information to show that this device is safe and effective.

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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has essential tremors. There is insufficient literature to support the use of the requested device as safe and effective for the enrollee's condition, as defined by Medicare rules. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170)

You asked the Plan to pre-approve additional mileage. You say that you are requesting additional mileage so you can get to a medical appointment. The Plan denied your request. The Plan says you are requesting an additional 23 miles for a total of 73 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 24 one-way trips and each one-way trip must not exceed 50 miles of driving distance. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for 28 hours per week.

You asked the Plan to pre-approve the 28 hours of weekly home health aide services. You say that you had knee replacement surgery two months ago and are still unable to daily activities. You say that you still need help, and it is not fair to reduce the home health services that were being provided. You say that your providers and the clinical documentation support the medical necessity of continued home health care for 28 hours per week. The Plan denied your request. The Plan says there is no documentation supporting the need for number of home health hours being requested for the complexity of services required.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 28 hours of weekly home health aide services. Our reviewer says that the criteria for coverage have not been met.

Our physician reviewer found the provided records do not document a level of impairment with the enrollee's present function to necessitate twenty-eight hours of service per week. The enrollee is reported to be independent with his basic activities of daily living though with some difficulty. Ten and a half hours of service per week appears to be adequate for the enrollee's needs at this time. 

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 28 hours of weekly home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services for 28 hours per week.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, home with home health and home physical therapy.

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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a
subdural hematoma and has been discharged home. Medical problems are stable. There are no complex nursing
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for diagnostic analysis of cochlear implant, LT, RT (92604x2) provided
July 21, 2021
You asked the Plan to pay for diagnostic analysis of cochlear implant. You say that please see enclosed medical
records supporting documentation showing the services were rendered for cochlear implant programming. The
Plan denied your request. The Plan says that payment adjusted because the payer deems the information
submitted does not support this many frequency of services.
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. We looked at the file and the Plan's rules. In this case, the Plan is using hearing
aid rules for the analysis of a cochlear implant. The code at issue is a payable code and the Plan has not
presented any evidence as to why it would not be covered. Based on this information, we decided that the
Plan's rules for coverage of diagnostic analysis of cochlear implant have been met. Therefore, we decided that
the Plan has to pay for diagnostic analysis of cochlear implant, LT, RT (92604x2) provided July 21, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all four mouth quadrants.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all four mouth quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged service (99358) provided on June 17, 2021.
You asked the Plan to pay for the prolonged service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 99309 and 99358.
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 99358 is a column II code to column I code 99309.
This code pair does not allow for a modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged service (99358) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six orthopedic office visits and treatment to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve six orthopedic office visits and treatment to be rendered by the out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on June 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON mental health services. You say that you have been using this provider for years so this should be covered. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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. You did not seek prior approval for these services from either the Plan or from your assigned primary care provider. 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 outpatient mental health services provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second office visit (procedure code 99214) provided to the enrollee on March 15, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an excessive number of units was reported for an established patient office or outpatient visit when each unit requires distinct encounters.

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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter." 

We find that CPT code 99214 is not supported in the medical record. Specifically, the records do not show that two visits were provided on this date. If two visits had been provided, CPT 99214 as two units would not have been the correct code to use in this case. There is a higher level code that would have been more appropriate.

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 a second office visit (procedure code 99214) provided to the enrollee on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a negative pressure wound therapy pump (NPWT) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this item has been utilized for four months already, and the measurements are showing that the size of the wound has increased.

The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy pumps are covered for up to four months. 

The file shows that treatment has lasted for four months at this point. This pump cannot be covered past four months of use. 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 pre-approve continued rental of a negative pressure wound therapy pump (NPWT) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist physician services provided on June 28, 2021.

You asked the Plan to waive the copayment for the specialist physician services. You say that the billing code is incorrect. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

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 $45 copayment for specialist services. 

You have been asked to pay a $45 copayment for the specialist physician services. Specialist physician services fall within the Physician/Practitioner Services, Including Doctor'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 copayment for specialist physician services provided on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom-fabricated occlusal orthotic stabilization device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit for temporomandibular joint (TMJ) disorder.
The Plan must follow Medicare rules. Medicare rules say that oral appliances generally are classified as dental devices and are not classified as durable medical equipment. The requested appliance is intended to treat TMJ disorder. This type of device is not covered. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom-fabricated occlusal orthotic stabilization device for the enrollee.