Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ostomy supplies and skin barriers (A4394, A4371, A5120, A4362, A4419, A4367, A4385), provided on May 5, 2020, through June 19, 2020.
You asked the Plan to pay for the ostomy supplies and skin barriers. You say that the items are medically necessary. The Plan denied your request. The Plan says the member was under a home health plan of care on the billed dates of service.
The Plan must follow Medicare rules. Medicare rules say that ostomy bags and supplies related to ostomy care furnished by an HHA are bundled while a patient is under a home health plan of care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ostomy supplies have not been met. Specifically, the record indicates that the member was under a home health plan of care on the billed dates of service. Payment for these supplies is bundled in the payment to the HHA. Therefore, we decided that the Plan does not have to pay for the ostomy supplies and skin barriers (A4394, A4371, A5120, A4362, A4419, A4367, A4385), provided on May 5, 2020, through June 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on October 13, 2021, by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the x-ray. 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 x-ray provided on October 13, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the enrollee needs noninvasive ventilation
to manage chronic respiratory failure and also prevent recurrent exacerbation. You state the enrollee needs a
targeted tidal volume as well as a back-up rate by average volume-assured pressure support (AVAPS) which
additional bilevel positive airway pressure (BiPAP) cannot provide. The Plan denied your request. The Plan
says the request for a home mechanical ventilator set in TTV-VAPS mode 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 the home ventilator. Our physician
reviewer found a home ventilator is not medically necessary. This patient has severe chronic obstructive
pulmonary disease (COPD) with repeated admissions for acute on chronic respiratory failure. The enrollee may
benefit from BiPAP support at night. But Medicare does not cover a home ventilator when used as BiPAP. And
the AVAPS mode of support can be provided via BiPAP at less cost to the enrollee. The denial is upheld.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on June 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. 

You say that services were provided so payment should be made. The Plan denied your request. The Plan says no prior authorization was obtained for the enrollee to get services from an out-of-network 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 an office visit provided on June 8, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on July 21, 2021.

You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on July 12,
2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by Medicare coding regulations.

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 97010 is "Application of a modality to 1 or more areas;
hot or cold packs."

We find that CPT code 97010 is not supported in the medical record. Specifically, this code has a status
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment
for other services not specified. 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 physical therapy
services provided to the enrollee on July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested SNF care have not been met.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing service needs nor skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested IRF care have not been met.

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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673), provided
on July 19, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary.
The Plan denied your request. The Plan says the items are not medically necessary.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673), provided on July 19, 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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you have not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 an autonomic nervous system function test (95923) provided
on September 7, 2021.
You asked the Plan to pay for nervous system testing. You say that you would like this claim reprocessed based
on the medical documentation. The Plan denied your request. The Plan says this testing service may not be
reported when an automated device is used to perform the test.
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 95923 is testing of autonomic nervous system function;
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential.
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 nervous system testing. Our reviewer says that the
documentation does not support payment for the code as billed. Our reviewer found Medicare has criteria for
reporting CPT 95923, and in this case procedure report does not include enough information to confirm criteria
has been met. To cite the procedure report "Sudomotor Function skin response evaluation indicated mild
dysfunction of the sweat glands indicating mild small fiber perfipheral neuropathy in feet. Printout of results
can be produced if needed". In this case, CMS criteria cannot be confirmed, as the procedure does not describe
the test performed, what equipment was used for the procedure, as well as, medical necessity.
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 nervous system testing have not been met. Therefore, we decided that the
Plan does not have to pay for an autonomic nervous system function test (95923) provided on September 7,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 13, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that services were provided, and payment should be
made. The Plan denied your request. The Plan says there was no prior authorization for the enrollee to see an
out-of-network 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 an office visit provided on May 13, 2021, by an
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on March 26,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says no supporting documentation has been received to support the denied code.
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 00813 is "Anesthesia for combined upper and lower
gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum."
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 services at issue in
this case were not supported by the medical records. Our reviewer found the medical records submitted does
not include documentation to validate 00813 as a reimbursable service performed on March 26, 2021.
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 not been met. Therefore, we decided that the Plan does not
have to pay for anesthesia services provided to the enrollee on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the scope exam of the voice box
(31575) rendered by the out-of-network (OON) provider on August 24, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the office visit (99203) and the scope exam of the voice box (31575) rendered by
the out-of-network (OON) provider on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 12, 2021, to
October 14, 2021.
You asked the Plan to pay for the acute inpatient hospital care. You say that you have had chest pain for a
while, but on October 12, 2021 your chest pain was the worst you have ever experienced so you decided to go
to the hospital. The Plan denied your request. The Plan says that none of the clinicals were present to meet
medical necessity for admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found the record shows that at the time of inpatient admission the admitting physician
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.
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 acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided from October 12, 2021, to October 14, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scan of the head or brain (70450) provided on June 30, 2021.

You asked the Plan to pay for CT scan services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.

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 70450 is a column II code to column I code 70496. 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 computed tomography (CT) scan of the head or brain (70450) provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) provided September 7, 2021.

You asked the Plan to pay for the diagnostic services. You say that the services provided on this date of service were rendered appropriately in response to the enrollee's medical condition. The Plan denied your request. The Plan says the claim must be submitted to the primary insurance carrier.

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 met its obligation with regards to coordination of benefits. Specifically, the Plan has The records show that the Plan is secondary. As the secondary insurer, the Plan cannot be held responsible for the diagnostic services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) provided September 7, 2021.