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

 We decided that the Plan does not have to pay for the duplex scans of extremity veins (93971) provided on July 22, 2021.  You asked the Plan to pay for the duplex scans. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We asked our physician 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 duplex scans. Our reviewer says that the review indicates that the provider did not bill as required by Medicare coding regulations. Per the 2021 National Physician Fee Schedule Relative Value File April Release CPT code 93971 is listed with a bilateral surgery indicator is "0". When the bilateral surgery indicator is 0 a bilateral procedure must be reported with 1 unit of service. There is no additional payment for the code if reported as a unilateral procedure because of anatomy or physiology. Our reviewer found we find the Medicare rule for payment of CPT code 93971-TC-RT (2 units), 93971-26-77-RT (1 unit) and 93971-26-RT (1 unit) for July 22, 2021.  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 duplex scans have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scans of extremity veins (93971) provided on July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound (93926) provided on July 19, 2021.  You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied 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 $150 copayment for outpatient diagnostic tests.   You have been asked to pay a $101.09 copayment for an ultrasound. Since the Allowed Amount for this service is less than the required copayment of $150, you have been asked to pay only $101.09. The service at issue falls within the outpatient diagnostic tests 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 an ultrasound (93926) provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar facet joint injections.  You asked the Plan to pre-approve lumbar facet joint injections. You say that this service is medically necessary to treat your pain. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that facet joint interventions will be considered medically reasonable and necessary when the enrollee has failed to respond to noninvasive conservative care management.   We looked at the file and Medicare rules. In this case, the medical records provided do not document any conservative treatment that you have failed. Without documentation of conservative therapy that has failed, this service will not be considered medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of lumbar facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the application of a cast (29075) and cast supplies (Q4010) provided on April 21, 2021.  You asked the Plan to pay for the application of a cast and cast supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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 application of a cast and cast supplies. Our reviewer says that CPT code 29075 does not meet criteria for billing or reimbursement consideration. CPT 29075 would be inclusive to CPT 25600 for closed fracture treatment. Closed treatment is that the fracture is not surgically opened. Casting and splinting a fracture is considered closed fracture treatment.  Only recasting or splinting should be reported separately. Documentation does not support this fracture was resplinted. Our reviewer found CPT code Q4010 does not meet criteria for billing or reimbursement consideration.  The procedure report does not document short arm cast fiberglass was used, therefore this 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 application of a cast and cast supplies have not been met. Therefore, we decided that the Plan does not have to pay for the application of a cast (29075) and cast supplies (Q4010) provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on June 30, 2021.  You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the adjacent tissue transfer. Our reviewer says that CPT code 14301 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that an  Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm  was performed on June 30, 2021, therefore this service cannot be verified.   Our reviewer found CPT code 14302 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) being performed on June 30, 2021. Also, 14302 is an add on code. In order for an add on code to be considered for reimbursement consideration, the primary code must be eligible for reimbursement. In this case, the primary code is not eligible for reimbursement so 14302 is not eligible for reimbursement.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (EGD) services provided on June 29, 2021.  You asked the Plan to pay for the services provided. You say that the medical records support the level of service provided. The Plan denied your request. The Plan says experimental services are not covered. 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 provided. Our reviewer says that the enrollee has been diagnosed with esophageal dyskinesia and spasm and gastric outlet obstruction in association with adult hypertrophic pyloric stenosis. In treatment, Appellant underwent EGD with Botox injected into the gastroesophageal junction. Of note, the esophagus was described at the time as normal, and the duodenum was readily intubated through a patent pylorus. The available records provide no studies aimed at assessing gastrointestinal function, either radiologic or manometric, to corroborate the dysmotility diagnoses as listed above to warrant Botox injection as provided. Therefore, the services were not medically necessary.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the esophagogastroduodenoscopy (EGD) services provided on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would not provide any additional services or a clinical 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 he 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. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Custom Prosthetic Partial Hand and Finger Prostheses for the enrollee.  You asked the Plan to pre-approve these services. You say that this will help the member live an independent life. The Plan denied your request. The Plan says that the requested prostheses cannot be covered.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The requested prostheses (NAKED PROSTHETICS, 3 FINGER SYSTEM MCP DRIVER and NAKED PROSTHETICS PIP DRIVER) exceed the patient's medical need and are not medically necessary. There is a lack of high quality evidence in the literature of functional outcomes for partial hand prosthesis with the requested body powered Naked prosthetics. Additionally, a review of the specifications reveals that the items exceed the patient's functional needs. Per the Naked Prosthetics Product Technical Specifications, the prosthetics are designed to get workers back to difficult jobs, and for people who use their hands in harsh environments.  All products are resistant to most common chemicals such as isopropanol, ethanol, acetone, and oil, as well as water, dust and dirt. The prosthetics come in multiple color options as well. These features exceed the patient's medical and functional need and do not meet the criteria for medical necessity. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Custom Prosthetic Partial Hand and Finger Prostheses for the enrollee.
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 do not feel that you are ready to go home yet, and rehabilitation would reduce your need to return to the hospital. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 with your current medical stability and no medical complexity, there is no need for rehabilitation physician supervision at least 3 times per week. At your current functional level, you will not be able to fully participate in - and benefit from - at least 3 hours of therapy per day for 5 days per week in an intensive rehabilitation therapy program. Your rehabilitation needs can be safely met in another setting such as a skilled nursing facility.  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: 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 IRF services are medically necessary for this enrollee, and they will not make significant gains as necessary for a safe return home in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's skilled therapy needs can be met in a lower level of care.  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 the enrollee's 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a left reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is scheduled/approved for a left reverse total shoulder arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) billed with the -59 modifier provided on May 3, 2021.  You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the code as billed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 CT scan services Our reviewer says that the documentation does not support payment for the services as billed.   Our physician reviewer found that based on the medical records provided the computed tomography scan and the computed tomography angiography scan were both performed during the same encounter and on the same anatomic area (head/brain) and thus were not separate and distinct procedures for the purposes of payment.   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 CT scan services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) billed with the -59 modifier provided on May 3, 2021.