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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, but not on a daily basis. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part-time basis appear appropriate in this case. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the independent rehabilitation facility (IRF) care provided March 26, 2021, to April 8, 2021.
You asked the Plan to waive the copayment for the IRF care. You say that you believe that this cost would be fully covered. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $310 copayment per day for days 1-7 and a $0 copayment per day for days 8-90 for inpatient hospital care. You have been asked to pay a total cost share of $2170 for the IRF care (7 days x $310 copayment). This service falls within the inpatient hospital care benefit category.
Although you believed you were receiving skilled nursing facility care, you were actually inpatient at an IRF. 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 independent rehabilitation facility (IRF) care provided March 26, 2021, to April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on March 17, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 office visit (CPT code 99213) provided to the enrollee on March 17, 2021, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that the records provided support the need for the number of physical therapy visits being requested. The Plan denied your request. The Plan says the 12 additional physical therapy visits are not considered 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 12 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 the enrollee's progress over a course of physical therapy visits is very good and the enrollee herself wants to transition to a gym, which she trialed with physical therapy and did well. The documentation does not support coverage for additional physical therapy visits beyond what the Plan has already agreed to cover. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) (CPT code 99072) provided to the enrollee on October 30, 2020.
You asked the Plan to pay for the supplies. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered 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. Our records indicate that procedure 99072, which has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) (CPT code 99072) provided to the enrollee on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous (IV) infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) (CPT code(s): 96365 and 96366) and cefazolin sodium, 500MG injection (CPT code J0690) provided to the enrollee from April 15, 2020, through April 20, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Healthcare Common Procedure Coding System (HCPCS) code J0690 (12 units) remains not supported. Service not supported without requested documentation. The medical records submitted do not include documentation for the billed date of service; therefore, the billed service cannot be verified. Current Procedural Terminology (CPT) code 96365 95 (1unit) remains not supported. Service not supported without requested documentation. The medical records submitted do not include documentation for the billed date of service; therefore, the billed service cannot be verified. Current Procedural Terminology (CPT) code 96366 95 (2 units) remains not supported. Service not supported without requested documentation. The medical records submitted do not include documentation for the billed date of service; therefore, the billed service cannot be verified. 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 intravenous (IV) infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) (CPT code(s): 96365 and 96366) and cefazolin sodium, 500MG injection (CPT code J0690) provided to the enrollee from April 15, 2020, through April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the JAK2 testing rendered on April 5, 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 there is no valid physician order.
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.
We looked at the file and Medicare rules. 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 JAK2 testing rendered on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 16, 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 submitted records do not support the billing of procedure codes 87186 and 87150.

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 87186 is susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate. The definition of code 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.

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 these services. Our reviewer says that the submitted records do not support the billing of procedure codes 87186 and 87150. Our reviewer found the submitted laboratory report does not document the method of testing performed to confirm microdilution or agar dilution was performed to support code 87186. There is not enough documentation to confirm the results of procedure code 87150; therefore, the code cannot be confirmed as being performed. 

We looked at this coder's review, the file, and Medicare rules. 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 laboratory services rendered on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT code 73721).
You asked the Plan to pre-approve the MRI. You say that you may have to have hip surgery and you want the MRI approved to see what is going on to keep you from having surgery. The Plan denied your request. The Plan says there is no documentation submitted that shows you have had trial and failure of six weeks of conservative measures.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our physician reviewer found there was no recent documentation suggested that you had a full course of conservative treatments including 4-6 weeks of physical therapy (PT) to justify MRI. No recent exam or reported symptoms suggested a red flag diagnosis was present to justify bypassing conservative treatment. Therefore, MRI will be considered not medically necessary at this time based on the provided documentation. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT code 73721).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa injections. You say that the medical records provided support the need for the injection services being requested. The Plan denied your request. The Plan says the Part B Step Therapy criteria are not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no evidence that the enrollee has tried and failed the Plan's required drugs of Synvisc, Durolane, and/or Gelsyn-3. There is no evidence that the Plan's required drugs would likely be less effective and/or likely have adverse effects on the enrollee. Use of the requested drug instead of the Plan preferred drugs is not medically necessary based on the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 21, 2020.

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 codes 95907, 95886, and 95955 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 95907 is nerve conduction studies, 1-2 studies. The 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 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 these services. Our reviewer says that you disagree with the denial. Our reviewer found the records state that Train of Four testing was performed. This does not support nerve conduction studies; therefore, code 95907 is not supported. There is no documentation of nerve conduction testing to support code 95886. The documentation states that continuous EEG monitoring was performed and code 95955 is not the most appropriate code for these services. 

We looked at this coder's review, the file, and Medicare rules. 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 testing services rendered on October 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded as 76770 provided on November 18, 2020.
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the submitted documentation does not support the service was performed 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 76770 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete.
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 ultrasound services. Our reviewer says that the documentation does not support the code as billed. Our reviewer found the documentation did not include a real-time imaging and documentation to support CPT 76770. Of note, there is an ultrasound of Kidney, however real-time with documentation is not documented and cannot be confirmed as performed. 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 ultrasound services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services coded as 76770 provided on November 18, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology services provided on April 2, 2021.
You asked the Plan to pay for the pathology services. You say that these services were medically necessary. The Plan denied your request. The Plan says that this provider is listed as a student, and students may not be paid by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial is based on the provider's taxonomy associated with the National Provider Identifier (NPI). The Plan states that this is listed as a student, and that Medicare does not make payment for medical students' services. While this is correct, the remaining publicly available evidence clearly demonstrate that the provider at issue is a licensed physician. Maximus has verified that the provider in enrolled in the Medicare program and also has an active, unrestricted medical license in the State. In addition, the taxonomy code listed in the NPI database has recently been updated to reflect that the provider is no longer a student. We find that denial of payment for this claim is not supported. Therefore, we decided that the Plan has to pay for the pathology services provided on April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on November
30, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested item was medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage
were not met for the requested item.

The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria 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 pay for the lumbar-sacral orthosis. Our reviewer
says that the requested item was not medically reasonable and necessary. Our physician reviewer found the
documentation does not reveal evidence that supports that the patient's pain is reduced by restricting trunk
mobility. There is no evidence of a recent injury or surgery to the spine or related soft tissues that requires the
orthosis to facilitate healing. There is no evidence on an objective physical exam of weak or deformed spinal
muscles. The requested L0650 lumbosacral orthosis is 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from March 25, 2020, through March 31, 2020.
You asked the Plan to pay for the SNF care. You say that you have gone back and forth with the Plan regarding this claim. You feel this is payable, and the stay was authorized by the Plan The Plan denied your request. The Plan says that this claim was denied as the level of service is different than the authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any supporting evidence to supports its denial of payment in this case. The file includes a copy of the authorization issued by the Plan for this SNF stay. It does not indicate that coverage is limited to any "level of care". In addition, the Plan does not provide any description or explanation of what is meant by the approved level of care versus the level of care billed. Moreover, in regard to SNF services, assignment of a level of care or payment group prior to the services being rendered is not appropriate. The payment group would not be known until after the services are rendered. Without a cogent rationale, this claim denial is not supported. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from March 25, 2020, through March 31, 2020.