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

 We decided that the Plan does not have to pay for the re-evaluation of physical therapy established plan of care provided on May 6, 2021.  You asked the Plan to pay for the re-evaluation of physical therapy established plan of care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.     In this case, the CPT Code Manual definition of code 97164 is re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.  We find that CPT code 97164 is not supported in the medical record. Specifically, this code was not billed with an appropriate "always therapy" modifier. Based on this information, we decided that Medicare rules for coverage of the re-evaluation of physical therapy established plan of care have not been met. Therefore, we decided that the Plan does not have to pay for the re-evaluation of physical therapy established plan of care provided on May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electroencephalogram (EEG) (95955) provided on December 10, 2020.  You asked the Plan to pay for the EEG. You say that this claim has been billed appropriately based on the medical records. The Plan denied your request. The Plan says the medical records do not support the services as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).  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 EEG. Our reviewer says that the documentation does not support the service as billed. Our reviewer found the documentation that was submitted was reviewed, and the criteria for coverage have not been met. CPT 95955 is considered a "special EEG" test, documentation supports real-time imaging. This is an incorrect code to report for "real-time" imaging. Subsequently, this procedure 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 EEG have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) (95955) provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E1007, E1012, E2300).  You asked the Plan to pre-approve a power wheelchair and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 a power wheelchair and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no documentation that the patient's mobility deficit cannot be helped by the use of a walker and the records specifically indicate a walker is recommended for use in the home.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and accessories have not been met. Specifically, you are able to use a walker/cane in your home. This means the wheelchair is not medically necessary. Because the base wheelchair is not medically necessary the accessories are also denied. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E1007, E1012, E2300).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 2, 2021.  

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for psychotherapy services have not been met.  

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service coded 99051 provided on April 3, 2021.  You asked the Plan to pay for the service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 99051 is service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.  We find that CPT code 99051 is not supported in the medical record. Specifically, this code has a status code of "B". This means that payment for this service is always bundled into payment for other services not specified and no separate payment is made. Based on this information, we decided that Medicare rules for coverage of the service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service coded 99051 provided on April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve the requested device. You say that the device was making it difficult to
breathe. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that positive airway pressure devices are only
covered under certain medical indications.

We looked at the file, and Medicare rules. In this case, medical records were not provided to show adherence to
the use of the device. Based on this information, we decided that Medicare rules for coverage of the requested
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve facet joint injections.  

You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration because this request is for therapeutic facet joint injections. The Plan denied your request. The Plan says that the member does not meet LCD criteria as the imaging shows mild arthritis.  

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 facet joint injections. Our reviewer says that while a single session of intra-articular steroids is within the standard of care there is no evidence to support a series of intra-articular injections and most of the evidence-based literature supports diagnostic medial branch blocks followed by radio frequency ablation. Our physician reviewer found a single set of intra-articular steroids is medically reasonable and 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 facet joint injections have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections.  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: 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 need to be transferred to an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The required skilled rehab and nursing services can be safely and effectively provided 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require physician supervision at least three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehab nursing needs are noted in the record. With your current functional level, you do not need intensive therapies consisting of at least three hours per day at least five days per week with a multidisciplinary approach to daily therapy. While you may benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate and less intensive setting.  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 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 you only require short-term additional acute care services that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current 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: Surgery
Decision: Favorable

 We decided that the Plan has to pay for transcatheter tricuspid valve repair surgery received on June 30, 2021.  You asked the Plan to pay for the services. You say that your worker's compensation is old, and no longer pays claims related to your heart, only to your pacemaker. The Plan denied your request. The Plan says that the claims in question are for the diagnosis listed on the worker's compensation claim.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has not met its obligation with regards to coordination of benefits. Specifically, there is no evidence that the plan has sent the bill to worker's compensation, directed the provider to send the bill, or paid for the services and then submitted a bill for reimbursement. Therefore, we decided that the Plan has to pay for transcatheter tricuspid valve repair surgery received on June 30, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an auricular stimulator.  You asked the Plan to pre-approve an auricular stimulator. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this device is not covered as its efficacy has not been established.  The Plan must follow Medicare rules. Medicare rules say that an auricular stimulator is non-covered by Medicare when used for acupuncture for any indication.  We looked at the file and Medicare rules. In this case, the auricular stimulator is to be used for acupuncture which is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that in-network providers do not specialize in your condition. The Plan denied your request. The Plan says this service could be provided by a participating 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 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 OON services. Therefore, we decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical assistant services for an excision of benign lesion (11406) provided on September 24, 2021.  You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for surgical assistant services have not been met.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 11406. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met.     Therefore, we decided that the Plan does not have to pay for surgical assistant services for an excision of benign lesion (11406) provided on September 24, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  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.   The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for non-surgical management of a subdural hematoma. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interrogation device evaluation provided on September 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the interrogation device evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drug provided on August 11, 2021.  You asked the Plan to pay for the self-administered drug. You say that you were told by an insurance representative that all doctor ordered services would be covered. The Plan denied your request. The Plan says self-administered drugs are not included in Part A or Part B coverage.  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 pay for the self-administered drug provided on August 11, 2021.   Benefits for the 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on May 13, 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 procedure code G0483 is 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.  In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes.     We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. 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 drug testing rendered on May 13, 2021.