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

We decided that the Plan does not have to pay for the laparoscopy (50541) provided on March 15, 2021.

You asked the Plan to pay for the laparoscopy (50541). You say that CPT code 50541 was billed with modifier XS to unbundle the service from CPT code 50543. You say that the supporting medical documentation should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says CPT code 50541 is considered inclusive to CPT code 50543.

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 50541 is laparoscopy, surgical; ablation of renal cysts.

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 laparoscopy (50541). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that CPT 50541 51 XS LT has a bundled relationship with 50543, however an acceptable modifier is allowed to unbundle the services, providing the medical records support the use on an appropriate modifier. In this case, the medical records submitted do not include sufficient documentation to validate that 50541 51 XS LT was performed as a separate/distinct procedure, therefore CPT code 50541 51 XS LT is not eligible for billing or reimbursement consideration. 

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 laparoscopy (50541) have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy (50541) provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve three surgical placements of an implant body: endosteal implants (D6010 x3), osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950), and a sinus augmentation with bone or bone substitutes (D7951).  You asked the Plan to pre-approve the endosteal implants, osseous, osteoperiosteal, or cartilage graft, and sinus augmentation. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit package.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three surgical placements of an implant body: endosteal implants (D6010 x3), osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950), and a sinus augmentation with bone or bone substitutes (D7951).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient mental health visit (99213, 90833) provided on
June 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient mental health visit. You say that as per credentialing status, this
provider is enrolled with the Plan and services are payable and the Plan is responsible to pay to the provider.
You also say you want the claim reviewed and payment to provider processed. The Plan denied your request.
The Plan says the rendering provider is a non-participating provider. The Plan also says that they did not
authorize any services for this provider.
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 an outpatient mental health visit (99213, 90833)
provided on June 23, 2021, by an out-of-network (OON) provider.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 the enrollee is improving and additional testing has been recommended prior to discharge. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits (97110).
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.
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 additional PT visits. 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 there is just one note by PT presented for review and details of the treatments do not support the medical necessity for the therapy sessions. In addition, there is no documentation to show progress or lack thereof from the therapy session/s. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits (97110).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits (G0151) for a total of 17 visits.
You asked the Plan to pre-approve 5 additional physical therapy visits. You say that the requested additional visits are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 5 additional physical therapy visits. Our reviewer says that that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that you have made progress with therapy and appear to be functioning at a level commensurate with a lower level of care. The denied 5 visits are not shown to be 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 5 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits (G0151) for a total of 17 visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1851) and suspension sleeve (L2397) provided on August 30 and September 9, 2021.
You asked the Plan to pay for a knee brace and 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 the information in the patient's medical record adequately supports the medical necessity for the item. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided records do not discuss the need for the item at issue.
Therefore, we decided that the Plan does not have to pay for a knee brace (L1851) and suspension sleeve (L2397) provided on August 30 and September 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Taltz.  You asked the Plan to pre-approve Taltz. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Taltz.     Benefits for Taltz 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug
benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.
Benefits for self-administered drug 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. You say that you were dissatisfied with the care and services you received from the in-network provider. The Plan denied your request. The Plan you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226).
You asked the Plan to pre-approve a lower partial denture. You say that you would like this service covered. Plan denied your request. The Plan says you have exceeded the frequency 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. The Plan covers a mandibular partial denture once every 60 months. We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial denture was previously covered on February 25, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of a lower partial denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).  You asked the Plan to pre-approve the total electric hospital bed. You say that the total electric hospital bed is medically necessary. The Plan denied your request. The Plan says this type of bed is non-covered.  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 (E0265).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee has spondylolisthesis above
a previous fusion site. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because studies have not proven that this is helpful for treatment of the enrollee's condition.
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 bone marrow aspirate. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate is experimental in spinal surgery when used as bone graft
material.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).  You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that you only have three teeth and are having trouble eating. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have a deformity that was caused from your surgery. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedure codes 36215, 75710) provided to the
enrollee on May 28, 2021.
You asked the Plan to pay for the services. You say that there are no edits to bundle CPT code 36215 and CPT
code 75710 is clearly documented. The Plan denied your request. The Plan says procedure codes 36215-59 and
75710 are not supported by the medical records.
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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found for CPT 75710 and CPT 36215,
documentation of access through a different site other than arteriovenous fistula (AVF) was not found in the
procedure report.
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 (procedure codes 36215, 75710) provided to the enrollee on May 28, 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 the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
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 based on the documentation provided there is no evidence that the enrollee requires
services that are not currently available at the present setting where she is receiving care. The enrollee can
remain at the current setting until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sacroiliac joint fusion (27279).
You asked the Plan to pre-approve the sacroiliac joint fusion (27279). You say that the patient has failed
medications, physical therapy and other non-interventional modalities. You say that evidence suggests a joint
fusion is a viable approach for sacroiliitis management with long term efficacy. The Plan denied your request.
The Plan says the enrollee does not meet the criteria for coverage.
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 sacroiliac joint fusion (27279). Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the patient has fibromyalgia and back pain, but the source of the pain is
not clearly defined. Our reviewer says that a sacroiliac joint fusion for degenerative back pain with sacroiliac
joint instability remains experimental.
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 sacroiliac joint fusion (27279) have not been met. Therefore, we decided
that the Plan does not have to pre-approve the sacroiliac joint fusion (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320) for tooth # 29.
You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan denied your request. The Plan says endodontic therapy, or root canal, is not a covered 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, the requested endodontic therapy is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3320) for tooth # 29.