Persius/hicric huggingface dataset:
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 SNF admission. You say that the enrollee would benefit from SNF care as she is not able to walk without risk of falling and cannot get out of bed without assistance. The Plan denied your request. The Plan says the enrollee's condition does not require daily skilled nursing or therapy care.  

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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 12/17/2021 due to possible pneumonia, urinary tract infection, and acute kidney injury. She requires minimal assistance to stand up, for bed/chair transfers, and to sit down. She also requires minimal assistance for walking up to 20 feet using a walker.   

The enrollee does not have documented skilled nursing needs. The enrollee does 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 the enrollee's condition. The enrollee's care needs are custodial and, 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 the SNF 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for treatment with PriMatrix skin substitute (Q4110) provided on May 3, 2021.  

You asked the Plan to pay for PriMatrix. You say that the requested treatment was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested treatment is experimental/investigational.  

The Plan must follow Medicare rules. Medicare rules say that clinical use of amniotic membrane derived skin substitutes outside of the care of DFU and VSU is not reasonable and necessary and non-covered.  

We looked at the file and Medicare rules. In this case, PriMatrix was used outside of the care of DFU or VSU. Based on this information, we decided that Medicare rules for coverage of PriMatrix have not been met. Therefore, we decided that the Plan does not have to pay for treatment with PriMatrix skin substitute (Q4110) provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services (97530) provided on May 27, 2021.  You asked the Plan to pay for occupational therapy services. You say that this should be covered as in-network. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel.   We looked at the file and Medicare rules. The service at issue was billed as incident to a physician's assistant's services, but the records do not show that he was present to directly supervise the occupational therapist. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (97530) provided on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an X-Ray examination (71045) provided on September 13, 2021.  You asked the Plan to pay for X-Ray 71045. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 71045 has a procedure-to-procedure (PTP) edit of 1 with code 71046 so is not separately payable without an appropriate modifier.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code X-Ray 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an X-Ray examination (71045) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on July 15, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed by a participating Plan provider and performed as a routine screening per your 2021 Evidence of Coverage.  Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.   We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist visit provided on March 3, 2021  

You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  

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 $40 copayment for each covered specialist visit.   

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit on March 3, 2021. You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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. Therefore, we decided that the Plan does not have to waive the copayment for the specialist visit provided on March 3, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology services rendered on May 27, 2021.  

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 the claim is a duplicate.  

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.         

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pathology services rendered on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on October 16, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.    The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the free soft tissue graft procedure of the first tooth (D4277) and two free soft tissue graft procedures of each additional contiguous tooth (D4278 x2) provided on August 25, 2021.  

You asked the Plan to pay for the free soft tissue graft procedures. You say that these procedures were necessary to save the three teeth involved. You also say that the goal was to rebuild the bone under the implants, the bone loss is a normal result of aging. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 pay for the free soft tissue graft procedure of the first tooth (D4277) and two free soft tissue graft procedures of each additional contiguous tooth (D4278 x2) provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a semi-electric hospital bed with side rails and an innerspring mattress, a patient hydraulic lift, and a manual wheelchair.  

You asked the Plan to pre-approve the hospital bed, lift, and manual wheelchair. You say that the requested equipment is medically necessary. The Plan denied your request. The Plan says the records provided are insufficient to justify that Medicare coverage rules are met for the requested medical equipment.  

The Plan follows Medicare rules. Medicare rules say that semi-electric hospital beds are covered for enrollees who require frequent changes in body position and/or an immediate need for a change in body position. Patient lifts are considered medically necessary when there is objective evidence that the enrollee would be bed confined without use of the lift and requires transfer out of bed. The Medicare rules for manual wheelchairs require that the enrollee have a documented mobility limitation that cannot be sufficiently resolved with a cane or walker.  

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 hospital bed, lift, and manual wheelchair. Our reviewer says that the documentation provided does not support that Medicare criteria are met for the requested equipment. Our physician reviewer found the documentation notes the patient's pain is controlled. There is no evidence of a need for frequent changes in body position and/or an immediate need for a change in body position. As such, the requested semi-electric hospital bed is not considered reasonable and necessary. This means that the requested side rails and mattress are also noncovered.  

As for the patient lift, there is no objective physical examination or functional evaluation indicating that the E0630 lift is reasonable and necessary. Without evidence of that patient's objective functional ability, the lift criteria have not been met.  

Lastly, in regard to the manual wheelchair, there is no objective physical exam or gait evaluation indicating that the patient has a mobility limitation and is unable to use a walker or cane. There is no objective evaluation of the patient's home indicating that the patient can safely maneuver the requested wheelchair in the home to participate in MRADLs. There is no physical examination of objective limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities. There is no neuromuscular lower extremity evaluation or gait evaluation.       

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 hospital bed, lift, and manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with side rails and an innerspring mattress, a patient hydraulic lift, and a manual wheelchair.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the echocardiography, transthoracic, real-time with image documentation (93306) provided July 30, 2021.  You asked the Plan to waive the copayment for the echocardiography. You say that this is a standard cardiology test and should have a $20 cost share. 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 $140 copayment for Medicare-covered radiological diagnostic services.   You have been asked to pay a $140 copayment for the echocardiography. The echocardiography falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. Echocardiography is a diagnostic radiology service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the echocardiography, transthoracic, real-time with image documentation (93306) provided July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  August 14, 2020.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that the various denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a skilled nursing facility (POS 31). 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 laboratory services provided to the enrollee on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical equipment (99072, A4556, A4557) provided  March 29, 2021.  You asked the Plan to pay for the medical equipment. You say that the items were medically necessary. The Plan denied your request. The Plan says the codes billed are not eligible for separate payment.  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 99072, A4556, & A4557 are not supported in the medical record. Specifically, per the National Physician Fee Schedule relative value file, these codes have a status of "B" and "P". Payment for these services is always bundled in payment for another service. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for medical equipment (99072, A4556, A4557) provided March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from November 16, 2020, to November 20, 2020.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was updated in this case.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    

In this case, you billed the inpatient services provided with . 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the medical record was incomplete to reflect a significant alteration in mental status, hemodynamic instability, abnormal serum platelet, or creatinine levels to support a life-threatening organ dysfunction related to a dysregulated response to infection. The review has determined that the records did not support the DRG and the diagnosis codes used in this case.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from November 16, 2020, to November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shower chair (E0240) provided on August 18, 2021.  You asked the Plan to pay for a shower chair. You say that the item at issue is a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair (E0240) provided on August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on June 25, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says non-emergent ambulance authorization was not obtained prior to the services being rendered.  The contract with the Plan says that authorization rules may apply for select ambulance services.  We looked at the file and the Plan's rules. The file shows that an authorization for the ambulance transport was required and not obtained. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on April 19, 2021.  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 the services are not separately payable.   The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  The provider submitted a claim for procedure codes 22853 (insertion of interbody biomechanical device), 22558 (lumbar spine fusion), and 77002 (needle localization by x-ray). Codes 22853 and 22558 are column II codes with a modifier indicator of 1 when billed with column I code 77002. The column II codes were not billed with an appropriate modifier to allow for separate payment. Billed procedure code 20930 (allograft, morselized) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on July 12, 2021 by an out-of-network (OON) provider.  


You asked the Plan to pay for lab test. You say that this service was performed out of medical necessity. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.  

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 laboratory testing provided on July 12, 2021 by an out-of-network (OON) provider.