Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648), a knee orthosis (L1851), and a suspension sleeve (L2397) provided on June 8, 2021.

You asked the Plan to pay for a lumbar-sacral orthosis, a knee orthosis, and a suspension sleeve. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.

Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648), a knee orthosis (L1851), and a suspension sleeve (L2397) provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services (62320) provided on October 4, 2021.

You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation is missing information required for payment.

The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. In this case, the Plan has sent several requests for medical records to corroborate the services received but no documentation has been returned. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services (62320) provided on October 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injection services.

You asked the Plan to pre-approve Supartz injection services. You say that the enrollee tried and failed
conservative treatment and the requested injections are clinically indicated. The Plan denied your request.

The Plan says the requested injection services are not medically necessary. The Plan says that there is no report
that the enrollee did not improve after a 3-month trial of conservative treatment, including medications,
physical therapy and steroid injection. The Plan says that there is no report that the enrollee is not a candidate
for knee surgery or that knee surgery is not planned within the next 6 months.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intraarticular
injections of hyaluronic preparations is covered for certain clinical indications and when medically
necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Supartz injection services. Our reviewer
says that the criteria for coverage have not been met. Our physician reviewer found the imaging supports a
grade 2 osteoarthritis of the right knee and also indicates other underlying conditions and possible causes of the
enrollee's knee pain, specifically, a displaced fracture, a tibial cyst, and a meniscus tear. However, there is no
report that these issues have been appropriately managed first.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Supartz injection services have not been met. Therefore, we decided that the
Plan does not have to pre-approve Supartz injection services.
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 IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF.

Specifically, you have not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 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: 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 requested SNF care is a medical necessity for
the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested SNF care
have 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 the requested SNF care is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. 

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT code 73721), for the enrollee.  You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your request. The Plan says there were no doctor notes given for this appeal. and without doctor notes, the Plan cannot determine if the imaging is medically needed.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found the record received states the findings as, "no fracture or dislocation. The osseaous structures are intact. Joint spaces are narrowed. Soft tissues are unremarkable. Impression: No acute osseous abnormality. Mild degenerative changes. Fragmented inferior patella enthesopyte noted. The medical records given for the appeal show an x-ray of the left knee revealing no acute osseous abnormality, mild degenerative changes, and fragmented inferior patellar enthesophyte noted. There were no other medical records submitted. There is no specific clinical rationale for the requested MRI. The review has determined that the requested MRI 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT code 73721), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
is currently unstable for transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder brace (L3960), provided on August 30, 2021.
You asked the Plan to pay for the shoulder brace. You say that the item is medically necessary. The Plan
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply
code; nor did documentation indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The documentation submitted does not indicate medical necessity or that the provider discussed the
need for this item. The record shows that the Plan made several attempts to obtain the necessary documentation
without success.
Therefore, we decided that the Plan does not have to pay for the shoulder brace (L3960), provided on August
30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (36215) provided on June 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 36215 is "Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family". 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 36215 is not supported by the records provided. Our reviewer found that the procedure report describes Vascular Access "Left Basilic Transposition AVF". Therefore, this procedure would not be coded 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (36215) provided on June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by a participating
provider.
You asked the Plan to pre-approve physical therapy. You say that you do not feel like you are fully fixed. The
Plan denied your request. The Plan says additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the requested services are not part of a maintenance program, are the
specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a
program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve physical therapy to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the steroid injection you received in your thumb at an outpatient hospital facility on August 17, 2021.

You asked the Plan to waive the copayment for the injection procedure. You say that you believe that the Plan incorrectly categorized this injection as a surgery. You stated this was a simple procedure in a treatment room, so the application of the outpatient surgery copayment is incorrect. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for outpatient surgery in an outpatient hospital facility. 

You have been asked to pay a $250 copayment for the injection procedure. The injection procedure falls within the outpatient surgery in an outpatient hospital facility benefit category. Medicare assigns certain procedure codes the designation of 'surgery' in its Medicare Physician Fee Schedule lookup tool. Any procedures that are considered surgeries are noted in this tool as having a 0, 10, or 90-day global surgical period. Any procedure codes where the 'global surgery' indicator is not 0, 10, or 90 (and, instead, it says N/A or XXX) means that the procedure is NOT considered a surgery. The injection procedure you had was billed with procedure code 20550. According to the Medicare Physician Fee Schedule lookup tool, this code has a global surgery period of 0, meaning that Medicare considers this procedure to be a surgery. In addition, you received this procedure at a facility that bills as an outpatient hospital. 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 steroid injection you received in your thumb at an outpatient hospital facility on August 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90791, 90837) provided on July 22 and August 5, 2021.

You asked the Plan to pay for psychotherapy services. You say that you got the wrong information from the Plan and were told the provider at issue was covered. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue is not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90791, 90837) provided on July 22 and August 5, 2021.

Your complaint about receiving erroneous or incomplete information about your provider network from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration services (procedure code
96401) provided to the enrollee on July 8, 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 the provider did not bill as required by Medicare coding regulations.
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 96401 is "Chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic."
We find that CPT code 96401 is not supported in the medical record. Specifically, our reviewer found that the
documentation shows that Xgeva was administered. HCPCS code J0897 should be used to report denosumab
(ProliaTM, XgevaTM) for claims submitted to the Part A and Part B MAC. The administration of denosumab,
when billed, should be billed using the therapeutic administration code 96372 (Therapeutic prophylactic, or
diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
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 chemotherapy administration services (procedure
code 96401) provided to the enrollee on July 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76937, 36000) provided on February 13, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 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, we have confirmed that code 76937 s is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. 

The rules also say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. Code 36000 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 36000. Therefore, we decided that the Plan does not have to pay for the services (76937, 36000) provided on February 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 26, 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 the provider did not bill as required by Medicare coding regulations.

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 70450 is a column II code to column I code 70496. 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. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.

You asked the Plan to pre-approve Feraheme. You say that this is medically necessary. The Plan denied your request. The Plan says that you have not tried and failed the preferred step therapy drugs.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that Feraheme is not medically reasonable and necessary. You have not tried and failed the required Infed and Venofer. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that your condition does not meet step therapy criteria for Feraheme. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.