Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia for procedures on lower anterior abdominal wall (00800) provided on September 1, 2020.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says there is a more appropriate anesthesia code that should have been 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 00800 is [*****enter CPT Codebook definition*****].  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 anesthesia services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found the anesthesia provider is reporting Anesthesia for "Removal Superpubic Catheter", however, Healthcare plan documents "52276 Cystourethroscopy with difect bision interal urethrotomy was billed by the surgeon. As there is no operative report to confirm exact location of this procedure, a correct anesthesia code cannot be verified.  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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for procedures on lower anterior abdominal wall (00800) provided on September 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the chest to screen for lung cancer for the enrollee.  You asked the Plan to pre-approve the screening. You say that this is medically necessary. The Plan denied your request. The Plan says a previous chest x-ray had stable abnormal findings.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 screening. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has only has 16 pack years of smoking history. There must be a tobacco smoking history of at least 30 pack years.  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 screening have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the chest to screen for lung cancer for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Eliquis tablet.  You asked the Plan to pre-approve Eliquis tablet. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Eliquis tablet.   Benefits for Eliquis tablet 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: Unfavorable

 We decided that the Plan does not have to waive the copayment and further pay for the services rendered by a chiropractor (98941, 99202, 72040, 72100) provided on August 6, 2021.  You asked the Plan to waive the copayment and further pay for the services rendered by a chiropractor. You say that you believe that these services should be covered as they were all medically necessary. The Plan denied your request. The Plan says the only service that is covered when performed by a chiropractor is the manual manipulation of the spine to correct subluxation. Therefore, they have correctly processed the claim by charging a $20 copayment and not covering the remaining services.  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 $20 copayment for Chiropractor services. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  You have been asked to pay a $20 copayment for the manual manipulation of the spine (98941) rendered by a chiropractor. These services rendered by a chiropractor fall within the Chiropractor services 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.  However, the records show that the remaining services at issue (99302, 72040, 72100) are not manual manipulations of the spine. These services include the office visit and X-ray services. When these services are performed by a chiropractor, they will not be covered by the Plan. Therefore, the Plan is not liable to pay any amount for these services and you will be charged the full amount the provider charged. Therefore, we decided that the Plan does not have to waive the copayment and further pay for the services rendered by a chiropractor (98941, 99202, 72040, 72100) provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires extended acute care services and would be best served in an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage.  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.   Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. 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 they are 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 300 units of Botox (J0585).  

You asked the Plan to pre-approve 300 units of Botox. You say that the 300 units are medically necessary. The Plan denied your request. The Plan says the requested amount exceeds the recommended dosage.  

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 300 units of Botox. Our reviewer says that 300 units of Botox are not medically necessary. Our physician reviewer found the Food and Drug Administration has stated that the recommended dose is 200 Units of Botox per treatment, and should not be exceeded.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 300 units of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve 300 units of Botox (J0585).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Kanjinti (Q5117) in combination with Abraxane and Gemcitabine.  You asked the Plan to pre-approve the requested drugs. You say that this drug combination is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of the requested drugs for the enrollee's condition have not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 requested drugs. Our reviewer says that the requested drug combination is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found that the record indicates that the enrollee has a diagnosis of metastatic pancreatic cancer. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended  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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Kanjinti (Q5117) in combination with Abraxane and Gemcitabine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).  You asked the Plan to pre-approve the complete maxillary denture. The Plan denied your request. The Plan says this service is allowed once per 5 calendar years. The Plan also says that the enrollee has already received this service within the past 5 years and has reached the limit for this service.    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, dentures are limited to 1 set every 5 years. The record shows that the enrollee has already received this service within the past 5 years and their maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).   Please Note: The enrollee has disenrolled from this plan effective January 1, 2022. The enrollee therefore would not have any benefits under this plan because we are currently in the 2022 benefit period.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography studies coded 51785 and the neuromuscular junction testing coded 95937 provided on July 9, 2021.  You asked the Plan to pay for the needle electromyography studies and the neuromuscular junction testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 51785 and 95937 are not supported in the medical record. Specifically, the technical report did not include documentation of needle electromyography studies (EMG) of the anal or urethral sphincter, using any technique; therefore, code 51785 cannot be verified. The technical report did not include documentation of neuromuscular junction testing (repetitive stimulation, paired stimuli) for each nerve, by any 1 method; therefore, code 95937 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the needle electromyography studies and the neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography studies coded 51785 and the neuromuscular junction testing coded 95937 provided on July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing (CPT code 88305) provided to the enrollee on September 1, 2021, by a non-participating provider.  You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 the laboratory testing (CPT code 88305) provided to the enrollee on September 1, 2021, by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records do not show that they require continued treatments and care that can only be given in a hospital setting. The Plan states they are recovering from an acute illness; however, they will need continued care, including oxygen and skilled therapy. The Plan states the enrollee can safely receive this care in another setting, such as in their current acute care facility, a skilled nursing facility (SNF), or at home with home health services or outpatient setting if appropriate.  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. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. 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 they are 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.  You asked the Plan to pre-approve a power seat elevation feature. You say that the requested feature is a medical necessity for you. The Plan denied your request. The Plan says the requested feature is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a first order of selective catheter placement billed with code 36245 and provided on March 31, 2021.  You asked the Plan to pay for codes 36245 or 36248. You say that the documentation provided supports the services in dispute. The Plan denied your request. The Plan says code 36245 is part of a coding pair edit and is not separately payable. The Plan also says that code 36248 was not billed with an appropriate primary code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   The records show that the Plan paid for code 37225. In this case, we have confirmed that code 36245 is a column II code to column I code 37225. This claim has not been billed with an appropriate modifier to bypass the edit.   The Current Procedural Terminology (CPT) code Manual definition of code 36248 is selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate.) Code 36248 is an add-on code and is defined as being appropriate only when listed in addition to an initial second or third order vessel, which would be represented by codes 36246 and 36247. The records do not show that an initial second or third order vessel was billed by the provider.  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a first order of selective catheter placement billed with code 36245 and a second order of selective catheter placement billed with code 36248 billed for date of service March 31, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you have no needs for SNF services.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services provided on May 10, 2021.  You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says HCPCS code 27488 denied due to lack of reporting of a device category HCPCS code required for the billed procedure and has a status indicator J1 for a comprehensive APC for a single payment for a primary service. The Plan must follow Medicare rules. Medicare rules say that hospitals paid under the OPPS (bill types 12X and 13X) that report procedure codes that require the use of devices must also report the applicable HCPCS codes and charges for all devices that are used to perform the procedures  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Specifically, this claim does not include a device category HCPCS code which is required for billed procedure code 27488. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the refraction services (92015) provided on July 22, 2021.  You asked the Plan to pay for the refraction services. You say that these services were medically necessary and should be paid for. The Plan denied your request. The Plan says that Medicare does not cover refractive procedures.  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 denied coverage based on the fact that Medicare does not provide coverage for eye refraction services. However, the enrollee's Evidence of Coverage clearly states that "one routine vision exam" is covered every 12 months which would indicate that the Plan provides supplemental vision care beyond what Medicare provides coverage for. If the Plan is denying coverage of the refraction services because they were not performed during a routine vision exam, it would have been appropriate to request medical records from the provider.  Therefore, we decided that the Plan has to pay for the refraction services (92015) provided on July 22, 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.