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

We decided that the Plan does not have to pre-approve the office services and treatment to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says there is an in-network provider that can perform the services you need.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services and treatment to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from November 2, 
2021, to November 29, 2021. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes are 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The CPT 
Code Manual definition of code 97140 is manual therapy techniques (e.g., mobilization/ manipulation, manual 
lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. 
 
The file shows that 97110-GP and 97140-GP were provided on November 3, 2021, November 5, 2021, and 
November 12, 2021. We find that the CPT codes are not supported in the medical record. The manual therapy 
services (97140) do not include the amount of time spent. The therapeutic procedures (97110) do not 
specifically indicate the exercises provided, or the amount of time spent. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the physical therapy services provided from November 2, 2021, to November 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 7 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 7 PT visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services 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 an additional 7 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 7 PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 7 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal system, above knee, flexible protective 
outer surface covering system (CPT code L5964). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says L5964 exceeds the enrollee's needs and cannot be covered under the Medicare criteria of 
reasonable and 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 item. Our physician reviewer found 
there is no documentation that the flexible protective outer surface covering system at issue in this case meets 
all Medicare criteria for medically reasonable and necessary for you. Provided records do not document that 
you have a special need for protection against unusually harsh environmental situations where it is necessary to 
protect the lower limb prosthesis beyond the level of protection that is afforded by the standard cover (L5705) 
which has been approved by the Health Plan. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endoskeletal system, above knee, flexible protective outer surface covering system (CPT code 
L5964).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has had frequent wash outs 
and continues to have vacuum assisted closures for a wound. You say that the enrollee has been to surgery 
multiple times and has to have total parenteral nutrition due to her nutrition state. The Plan denied your request. 
The Plan says a LTACH admission is not medically necessary, and the enrollee can safely receive the care they 
need in a SNF. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the rescue 
squad was called twice to stop a severe nosebleed, in which transportation was deemed unnecessary. You also 
say that you believe this service should be covered under the urgently needed services as described in your 
Plan's information booklet. The Plan denied your request. The Plan says this service is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19371 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 19371. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 19371 is bundled into 
payment for code 19330. 
 
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 19371 
is a column II code to column I code 19330. 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 procedure code 19371 billed for date of service April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (20680) and arthrodesis (28750) provided on March 1, 2022.

You asked the Plan to pay for the implant removal (20680) and arthrodesis (28750). You say that the operative report clearly indicates both codes as performed. You say that the claim should be reviewed, and payment allowed for both procedure codes. The Plan denied your request. The Plan says procedure codes 20680 and 28750 are not supported by the medical records submitted.

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 20680 is removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate). The CPT Code Manual definition of code 28750 is arthrodesis, great toe; metatarsophalangeal joint.

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 implant removal (20680) and arthrodesis (28750). Our reviewer says that the documentation submitted was reviewed and does not meet criteria for coverage. Our reviewer found that the operative report describes hardware removal with plate and screw fixation. In this case, the hardware removal would be inclusive to the primary procedure. The procedure report also does not include documentation that increased procedural services were performed, as well as intensity or time, technical difficulty of the procedure, increased physical and mental effort required. Therefore, modifier 22 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 implant removal (20680) and arthrodesis (28750) have not been met. Therefore, we decided that the Plan does not have to pay for the implant removal (20680) and arthrodesis (28750) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a kidney dialysis provided on May 31, 
2022. 
 
You asked the Plan to waive the coinsurance for dialysis services. You say that you were never told that you 
would be charged for these services. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for services to treat kidney disease/in- and out-of-network for dialysis services in all places of 
service.  
 
You have been asked to pay a $60.81 for coinsurance for kidney dialysis. The total allowed for kidney dialysis 
is $304.04. The amount you are being asked to pay is 20% of $304.04 ($304.04 x 20% =$60.81).  This 
item/service falls within the services to treat kidney disease/in- and out-of-network 20% coinsurance for 
dialysis services in all places of service. 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 coinsurance 
for a kidney dialysis provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Artacent wound skin substitute. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is considered experimental. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a scalp wound related to squamous cell carcinoma. Available clinical 
studies measuring the effectiveness of this product is limited and not high quality yet to broadly support its use 
in this clinical situation. Therefore, this request for Artacent is considered not medically necessary at this time. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Artacent wound skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is to be used for the 
treatment of COPD and OSAS. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD, OSA, 
and obesity-hypoventilation syndrome. The OSA is being effectively treated with BiPAP. ABG apparently 
done during an outpatient visit while the enrollee was stable, and while using BiPAP at night, showed elevated 
pCO2 of 62. However, the pO2 was 48, suggesting this was a venous sample or a mixed sample. Nevertheless, 
it suggests the enrollee may have persistent CO2 retention despite BiPAP during sleep. It would be reasonable 
to change to BiPAP with AVAPS and a backup rate. But Medicare does not cover a home ventilator when used 
as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services (93000) provided on March 15, 2022.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code 93000-59 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 93000 is "Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report".

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 use of code 93000 is supported by the records provided. Our reviewer found that the documentation states, "He presents for evaluation of the following symptoms: chest pain, palpitations, and shortness of breath". The documentation describes and ECG was performed, with interpretation documented in the evaluation and management report. In this case, CPT 93000 was appropriate to perform and bill separately with modifier -59 as this procedure was not routine and was performed in regard to the diagnosis. The documentation supports that the ECG was a separate procedure in this case.

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 been met. Therefore, we decided that the Plan has to pay for the services (93000) provided on March 15, 2022. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 routine transportation trips (A0120).

You asked the Plan to pre-approve an additional 10 routine transportation trips. You say that you need transportation to your medical appointments. The Plan denied your request. The Plan says thirty-four (34) one-way transportation trips have been exhausted so far this year. You have two (2) one-way transportation trips remaining for the 2022 calendar year, and then the transportation benefit will be exhausted, and no additional trips can be approved.
 

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 10 routine transportation trips (A0120).
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 the enrollee meets the Medicare criteria for IRF 
admission. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not 
met and the enrollee's needs can be met at a skilled nursing facility (SNF). 
 
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 enrollee is medically stable with no acute medical illness and does not need 
physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute 
nursing needs identified or documented. The enrollee has chronic problems with bladder and bowel issues. 
With initial dependency for mobility and activities of daily living, the enrollee will not make a significant 
functional progress in the predicted period of 14 days. The enrollee will need a long-term rehabilitation in an 
alternate setting such as in an SNF. The enrollee does not need 3 hours a day of therapies for 5 days a week 
with multidisciplinary approach in an IRF. The enrollee's rehabilitation needs can be safely met in a lower 
intensity setting. 
 
The documentation does not support the medical necessity for admission to an IRF due to lack of medical 
complexity and lack of nursing needs. While the enrollee would benefit from Speech, physical therapy and 
occupational therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the documentation does show that the enrollee has complex functional impairments 
however there is no rehabilitation diagnosis for monoplegia or active medical comorbidities listed. Without a 
definitive rehabilitation diagnosis there would be no way to determine if the enrollee would significantly 
benefit from an intense therapy regimen and without active comorbidities there would be no need for continued 
inpatient hospitalization during rehabilitation. 
 
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.