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

We decided that the Plan does not have to pay for the testing services rendered on October 9, 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 procedure codes 95938, 95861, 95940, A4215, and A4556 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 95938 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs. The definition of code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 

We find that CPT codes 95938, 95861, and 95937 are not supported in the medical record. Specifically, there is no documentation of short-latency somatosensory evoked potential study to support code 959385. There is no documentation of needle electromyography of two extremities to support code 95861. There is no documentation of neuromuscular junction testing to support code 95937.

The rules say that procedure codes with a status indicator of X are statutorily excluded.

Billed procedure codes A4215 (sterile needle) and A4556 (electrodes pair) have a status indicator of X and are statutorily excluded from Medicare.

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 testing services rendered on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen device.

You asked the Plan to pre-approve the portable oxygen device. You say that the claim should be paid; your
current oxygen concentrator does not last long enough. The Plan denied your request. The Plan says the
enrollee has previously received the same supplies within the 5-year RUL.

The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.

We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has multiple oxygen concentrators. Records show this still within the 5-year RUL and the
documentation submitted does not show that it is irreparably worn, irreparably damaged, or that the enrollee
had a change in medical condition to warrant the device at issue. Based on this information, we decided that
Medicare rules for coverage of the portable oxygen device have not been met. Therefore, we decided that the
Plan does not have to pre-approve portable oxygen device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for routine vision hardware provided on May 27, 2021.

You asked the Plan to pay an additional amount for routine vision hardware. You say that the Plan advised you that coverage for the vision hardware is within the calendar year, so you proceeded with the appointment. The Plan denied your request. The Plan says the routine vision hardware services provided on May 27, 2021 exceeded the $220 maximum. Any charges above the benefit maximum of $220 for routine vision hardware is the member's responsibility.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan paid the benefit maximum allowance. Therefore, we decided that the Plan does not have to pay an additional amount for routine vision hardware provided on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to SSM Day Institute outpatient rehabilitation
program.

You asked the Plan to pre-approve admission to SSM Day Institute outpatient rehabilitation program. 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. 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 admission to SSM Day Institute
outpatient rehabilitation program. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found admission to the SSM Day
Institute outpatient rehabilitation program exceeds your medical needs and is not medically necessary. You are
at a high functional level and does not require an intensive program with 3 disciplines of physical therapy (PT),
occupational therapy (OT), and speech therapy (ST) in a Day Institute program. Your needs can be safely and
effectively met with a home or outpatient therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to SSM Day Institute outpatient rehabilitation program have not been
met. Therefore, we decided that the Plan does not have to pre-approve admission to SSM Day Institute
outpatient rehabilitation program.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 27, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. The rules also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.

We looked at the file and Medicare rules. Payment for HCPCS/CPT codes ABC is not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Additionally, based on review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Wisconsin. 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 provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).

You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
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 care could be received in another 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 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 have a past medical
history of stroke, diabetes and hypertension and is living at home with problems with ambulation and mobility.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from January 13, 2021, to
March 5, 2021.

You asked the Plan to pay for the dental services. You say that you feel you are being overcharged for your
dental care. The Plan denied your request. The Plan says they have covered the full $1,000 annual maximum
for you for dental services in 2021. You are responsible for any costs that exceed this amount.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover up to
$1,000 per year for supplemental preventative and supplemental comprehensive dental care.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plan's $1,000 annual maximum are not covered under this benefit. Documentation shows that the Plan has paid the benefit maximum of $1,000 for your supplemental dental care in 2021. Therefore, we decided that the Plan does not have to pay for the remaining dental services provided from January 13, 2021, to March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says alternate settings can be reviewed.

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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
has a past medical history of congestive heart failure, hypertension and cecal cancer who is living at home
receiving outpatient wound care for pressure ulcers of the thighs. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that you cannot manually adjust a bed throughout the night. The Plan denied your request. The Plan says that a total electric bed is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided April 22, 2021.

You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you would like additional coverage for the services. The Plan denied your request. The Plan says the out-of-network claims were processed correctly.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodic oral exam and dental cleaning twice a year with 50% coinsurance when provided out-of-network. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. 

We looked at the file and Medicare rules. The Plan provided documentation showing that coverage for 50% of the maximum allowed amount. 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 pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records provided do not show the therapy needed is only available at the skilled nursing facility.

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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not seem to qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. You appear to be reaching a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs, as a practical matter, can be provided at a lower level of care (ex. intermittent therapy, restorative nursing therapy, long term 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS device, pneumatic compression vasopneumatic device and multivitamin injection provided on July 20, 2020.

You asked the Plan to pay for the TENS device (97032), pneumatic compression vasopneumatic device (97016) and injection (J3490). You say that the enrollee needed the procedures because of cramping, throbbing feet. The Plan denied your request. The Plan says the vasopneumatic device is only for the treatment of chronic venous insufficiency with venous stasis ulcers or refractory lymphedema. The vitamin injections are not a Medicare covered service and the TENS device is not a Medicare covered benefit with the available information.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service. The vasopneumatic device is to reduce edema or lymphedema, treatment of foot pain with this device is not considered medically reasonable and necessary. There is no medical history of 3 months of foot pain or modalities, therefore criteria of the TENS device are not met. Based on this information, we decided that Medicare rules for coverage of the TENS device (97032), pneumatic compression vasopneumatic device (97016) and injection (J3490) have not been met. Therefore, we decided that the Plan does not have to pay for the TENS device, pneumatic compression vasopneumatic device and multivitamin injection provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home services provided on February 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for rest home services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services were not rendered in a participating facility.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for rest home services provided on February 1, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the medication is 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 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the regimen is not compendia approved or literature supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
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 October 6, 2020.
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.
You are 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 October 6, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from September 15, 2020, to September 19, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the services were billed without a PDPM code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The services in this case were billed with PDPM code "MJID1", which is a valid PDPM code for SNF services. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from September 15, 2020, to September 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.