Persius/hicric huggingface dataset:
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 criteria for IRF admission, and these services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met 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 based on the enrollee's current medical stability and lack of medical complexity, there is no need for physician 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 rehab nursing needs. At her current functional level, the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach to daily therapy. Documentation does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical and occupational therapies, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 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 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 medical services coded as 95955, 95885, 95937, 95927, and 95907 provided July 20, 2021.

You asked the Plan to pay for the medical services. You say that these services are supported in the medical records. The Plan denied your request. The Plan says the documentation does not support the codes 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 the billed codes are as followed:

95955 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
95885 - Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) 
95937 - Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
95927 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 
95907 - Nerve conduction studies; 1-2 studies

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 medical services. Our reviewer says that the services as billed are not supported in the medical records. Our reviewer found the following:

CPT 95955 - Documentation supports "real time" monitoring. There is a more appropriate CPT/HCPCS code to report for this service, and additional monitoring would be included in the correct reported code. 
CPT 95885 - This procedure is performed with nerve conduction studies, as no nerve conduction studies are documented this procedure would not be covered. All procedures in a code description must be performed, if only part of the description is performed, an appropriate modifier would be appended. 
CPT 95937 - Documentation does not include documentation of neuromuscular junction testing. Unable to cite report as this procedure is not documented. CPT 95927 - Documentation supports ulnar nerve stimulation with recording at Erb's point. This is the incorrect code to report for this serve. Procedure performed would be included with Ulnar nerve somatosensory evoked potential. 
CPT 95907 - Documentation supports "pedicle screw" stimulation. Nerve conduction studies is an inappropriate code to report for this procedure, as nerve conduction studies measure amplitude and latency/velocity. Therefore, this procedure would not be covered.

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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95937, 95927, and 95907 provided July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the back brace you received on June 24, 2021.  

You asked the Plan to waive the coinsurance for the back brace. You say that you were the victim of fraud where over $58,000 was removed from your bank account.  You said that as a result, you cannot afford this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for prosthetic devices.   

You have been asked to pay 20% coinsurance for the back brace. The back brace falls within the prosthetic devices benefit category. This cost sharing applies regardless of financial circumstances. 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 the back brace you received on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure provided on August 25, 2021.

You asked the Plan to waive the copayment for an outpatient surgical procedure. You say that the facility you were originally in could not perform the procedure so you had to be transferred to another facility which is why you are being charged the copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You have been asked to pay a $400 copayment for an outpatient surgical procedure. An outpatient surgical procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgical procedure provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) provided January 22, 2021.

You asked the Plan to pay for the critical care services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service 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 99291 is critical care, first hour. 

We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records submitted does not include a critical care evaluation and management note supporting 30-74 minutes of critical care. Critical care is a time-based service and for each date and encounter entry, the physician's progress notes, shall document the total time that critical care was provided. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on April 1, 2021.  

You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says that the Plan does not have out-of-network benefits.  

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a network optical provider.  

We looked at the file and the Plan's rules. The file shows that they eyeglasses were not purchased from a network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on  April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated wheelchair.

You asked the Plan to pre-approve a power operated wheelchair. You say that the requested power wheelchair is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

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. 

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cryoablation of axillary lymph node provided on May 21, 2021.

You asked the Plan to pay for the cryoablation of axillary lymph node. You say that this service was medically reasonable and necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of this procedure have not been demonstrated at this time.

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 pay for the cryoablation of axillary lymph node. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found cryoablation of axillary metastases is not yet considered a standard of care. Other techniques such as radiation are better studied. The service is not reasonable or 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 cryoablation of axillary lymph node have not been met. Therefore, we decided that the Plan does not have to pay for the cryoablation of axillary lymph node provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 7, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by the Plan if performed by participating provider and performed as a routine vision screening.

The Plan follows Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for venipuncture (36410-59) provided on March 31, 2021.

You asked the Plan to pay for venipuncture. You say that this was billed correctly. The Plan denied your request. The Plan says the billed modifier is not supported.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the record shows that this was performed in the same encounter as and in conjunction with the other billed services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for venipuncture (36410-59) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services (99343, 99203) provided in Mexico September 16, 2020 to December 21, 2020.

You asked the Plan to pay for the office visit and physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent and provided outside the United States. These services are not eligible for coverage.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 

We looked at the file and Medicare rules. The services were provided outside the United States and were non-emergent. Based on this information, we decided that Medicare rules for coverage of the office visit and physician services have not been met. Therefore, we decided that the Plan does not have to pay for an office visit and physician services (99343, 99203) provided in Mexico September 16, 2020 to December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided February 23, 2021.

You asked the Plan to pay for the office visit. You say that you should not be charged because this is an office visit and you have $0 copay. The Plan denied your request. The Plan says this service is not covered by Medicare as the services are for pre-employment to be a bus driver.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Services required by a third party, such as those required by employment, insurance, licensing, marriage and court-ordered examinations are not covered under Original Medicare. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) provided February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.

You asked the Plan to pre-approve twelve (12) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is 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 twelve (12) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are 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 twelve (12) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal maintenance (D4910), localized anesthesia for tooth #4, #6, #8, #10, #12, #14, #18, #20, #22, #24, #28, #30 (D4381), guided tissue regeneration for tooth #2, #3, #25, #26 (D4266), bone replacement graft for ridge preservation on tooth #2, #3, #25, #26 (D7953), tooth cleaning of heavy deposits (D4355) and application of desensitizing medicament (D9910).  

You asked the Plan to pre-approve dental services. You say that you disagree with the denial and are requesting approval of the requested dental services. The Plan denied your request. The Plan says the dental services requested are not listed and therefore are not covered services under the member's Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   

We looked at the file and Medicare rules. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The EOC confirms that a tooth cleaning of heavy deposits is covered once per every 3 calendar years and is only covered when there is substantial gingival inflammation in all four quadrants. The EOC also confirms that it is not allowed for one calendar year following any of D1110 or D1120 or any D4000 series code and it cannot be performed day or less than 1 calendar year after D0120 and D0150. Our records show that the member received a comprehensive oral evaluation (D0150) on October 7, 2021 and therefore, the benefit is exhausted. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance (D4910), localized anesthesia for tooth #4, #6, #8, #10, #12, #14, #18, #20, #22, #24, #28, #30 (D4381), guided tissue regeneration for tooth #2, #3, #25, #26 (D4266), bone replacement graft for ridge preservation on tooth #2, #3, #25, #26 (D7953), tooth cleaning of heavy deposits (D4355) and application of desensitizing medicament (D9910).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical testing services coded as 95909, 95886, 95955, and 95937 provided June 2, 2021.  

You asked the Plan to pay for the medical testing services. You say that the documentation supports the testing services as billed. The Plan denied your request. The Plan says the billed codes are not supported in the medical 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.  

In this case, the CPT Code Manual definitions of the billed codes are as follows: 

95909 -  Nerve conduction studies; 5-6 studies  
95886 -  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)  
95955 -  Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)  
95937 -  Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the medical testing services. Our reviewer says that the documentation does not support the testing codes as billed. Our reviewer found the following:  

CPT 95909 - Per documentation "Electrical Stimulation of the pedicle screws were evaluated by using triggered electromyography performed by stimulating each screw and recording a compound muscle action potential response in the appropriate muscles.  A response to stimulus intensities of 8.0mA or less raises concern for improper screw placement and potential breach in pedicle wall. This is an inappropriate code to report, as nerve conduction studies measure amplitude, latency/velocity.  Therefore, this procedure code would not be covered.  

CPT 95886 - Per CPT code description, this procedure includes nerve conduction studies.  As nerve conduction studies are not documented in the procedure, this service would not be covered.  

CPT 95955 - There is a more appropriate CPT/HCPCS code to report for this service, any additional electrocardiogram during surgery would be included in the correct reported code.  

CPT 95937 - Documentation does not include documentation of neuromuscular junction testing.  Unable to cite the report, as this procedure was not found in documentation submitted.  

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 medical testing services have not been met. Therefore, we decided that the Plan does not have to pay for the medical testing services coded as 95909, 95886, 95955, and 95937 provided June 2, 2021.