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

We decided that the Plan does not have to pay for the neuromuscular procedures represented by codes 95886, 95908, and 95937 provided on July 30, 2019.

You asked the Plan to pay for codes 95886, 95908, and 95937. You say that the medical records support the billing of codes 95886, 95908, and 95937. The Plan denied your request. The Plan says the medical records do not support the billing of codes 95886, 95908, and 95937.

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 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95908 is Nerve conduction studies; 3-4 studies. The definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.

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 codes 95886, 95908, and 95937. Our reviewer says that the medical records do not support the billing of codes 95886, 95908, and 95937. Our reviewer found in this case nerve conduction studies were not done. There was also no testing of the paraspinals done. Rather, in intraoperative EMG most of the time needles are simply placed in the major muscles and the paraspinals are not sampled. This service was not billed/coded properly. The services performed were triggered EMG. This was done as part of the pedicle screw testing. There was no evaluation of nerve conduction from a surface electrode. Nor were the results reported as a NCS. This was simply use of triggered EMG which falls under the scope of CPT codes for EMG. CPT code 95937 reflects a diagnostic test/testing used to evaluate neurological conditions involving the neuromuscular junction (e.g. myasthenia gravis). The testing that was done in this case was train of four testing. It is not otherwise appropriate/proper to code train of four testing with CPT code 95937--as the service provided does not test for disorders of the NMJ. As such this code was also submitted incorrectly.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95886, 95908, and 95937 have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular procedures represented by codes 95886, 95908, and 95937 provided on July 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that you attached clinical information to be reviewed due to the denial of additional physical therapy. The Plan denied your request. The Plan says additional visits are not medically necessary.
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 6 additional physical therapy 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 that the patient has had extensive prior therapy and can transition to an independent home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on March 2, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the drug testing provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve water therapy.

You asked the Plan to pre-approve the water therapy. You say that you would like reconsideration because this therapy is a more cost effective and non-invasive method to improve the member's overall health, strength, stability and mental health. The Plan denied your request. The Plan says that the requested service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 water therapy. Our reviewer says that the provider has described failure of traditional physical and occupational therapy treatments for this enrollee and treatment in an aquatic environment appears to be medically reasonable and necessary in this case. Our physician reviewer found Medicare states that aquatic physical therapy is a covered benefit. 

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 water therapy have been met. Therefore, we decided that the Plan has to pre-approve water therapy.

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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Zarxio Injection.

You asked the Plan to provide filgrastim-sndz, biosimilar, (zarxio), 1 microgram (Q5101). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee's absolute neutrophil count was normal, ensuring that this medication is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 provide filgrastim-sndz, biosimilar, (zarxio), 1 microgram (Q5101). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found weekly carboplatin and paclitaxel are not associated with significant risk of neutropenic fever. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of filgrastim-sndz, biosimilar, (zarxio), 1 microgram (Q5101) have not been met. Therefore, we decided that the Plan does not have to provide Zarxio Injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of cataract with insertion of prosthetic lens (66984) provided on March 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the removal of cataract with insertion of prosthetic lens. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 the removal of cataract with insertion of prosthetic lens (66984) provided on March 10, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the health plan sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR Section 424.5. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3 Section 3.3.2.1. The rules say that an order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from March 3,
2021, to April 22, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you were told by the provider
that all visits were covered by insurance. You also state you trust their words, but the visits are not all covered.
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 physical therapy is
covered, however, you must pay a $40 copayment for each Medicare-covered physical therapy service.
You have been asked to pay a $40 copayment for each Medicare-covered physical therapy service. You had
eight physical therapy sessions, for a total of $320 (8 therapy sessions x $40 for each session = $320). Physical
therapy falls within the Outpatient Rehabilitation 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 physical therapy provided from March 3, 2021, to April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a health club membership (S9970) for the 2020 benefit allowance.
You asked the Plan to reimburse you an additional amount for a health club membership. You say that you would like reconsideration of reimbursement. The Plan denied your request. The Plan says you have exceeded the $300 benefit allowance.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility. The services at issue in this appeal are gym benefits. You have a Wellness Allowance Benefit maximum of $300. The records show that in June 2020, you were reimbursed $150 by the Plan and in May 2021, you were reimbursed $102 by the Plan, towards your 2020 Wellness Allowance Benefit. The records also show that you submitted proof of payment for an additional allowance, and you are only entitled to be reimbursed $48 since you have now reached your maximum allowed benefit ($150 + $102 + $48 = $300). We find that the Plan does not have to reimburse you the remaining balance for your health club membership as you have exhausted your benefit allowance. Therefore, we decided that the Plan does not have to reimburse you an additional amount for a health club membership (S9970) for the 2020 benefit allowance.
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 LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 patient is an 81-year-old male who was admitted to the current acute care hospital 
with coronavirus after failing antibiotics, steroids, and bronchodilators as outpatient. The patient appears to be 
improving gradually and is likely to only require short-term additional acute care services, including weaning, 
which can safely be received at the current facility. The patient does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time as transfer would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on April 28, 2021.
You asked the Plan to pay for the ambulance services. You say that the transportation services were medically necessary as the enrollee is confined to a bed. You also say, due to coronavirus, this claim should be overturned and paid accordingly. The Plan denied your request. The Plan says transportation from a skilled nursing facility to a physician's office is not covered by Medicare.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the non-emergency ambulance services are not medically necessary. Our physician reviewer found the enrollee required transportation to a scheduled appointment. The reviewer found that the provided documentation indicates this transportation was not urgent. The reviewer found there was no indication a stretcher van was not available, which would have been appropriate at the time of transport as there was no acute condition to treat during transport. Therefore, the ambulance services are considered 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 ambulance services have not been met. Specifically, the file indicates that the transportation was for a scheduled appointment. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on April 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) services provided by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151 x 14).

You asked the Plan to pre-approve 14 additional PT visits. You say that you are having a hard time walking with your prosthesis. You say that your recovery has been slow. You also say that the requested services are medically necessary. The Plan denied your request. The Plan says the physical therapy discharge notes indicate that all physical therapy treatment goals were achieved. The Plan says that you have been instructed in a home program. The Plan also says that the requested home physical therapy services are not medically necessary.

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 14 additional PT visits. Our reviewer says that the additional 14 PT visits are not medically necessary. Our physician reviewer found the provided documentation indicates that you are functioning at or near your baseline. The reviewer also found that your ongoing therapy needs can be provided at a lower level of care. Therefore, the reviewer found that requested, ongoing, home health physical therapy is not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 14 additional PT visits have not been met. Specifically, the file indicates that you are functioning at or near your baseline. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) services provided by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151 x 14).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 23, 2021.

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 the services are not covered.

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 March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on December 16, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve this service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on December 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73630) provided April 23, 2021.

You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your request. The Plan says the deductible was not met at the time services were rendered. Additionally, the $10 copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible and a $10 copayment which applies to the x-rays. 

The item or service you asked the Plan to pay for falls within the benefit category the x-rays. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible and a $10 copayment which applies to the x-rays. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on April 23, 2021. Therefore, we decided that the Plan does not have to pay for an x-ray (73630) provided April 23, 2021.